Toward a Model of Safety and Care for Trauma Room Design

PI: Sara Bayramzadeh Patient Safety Learning Laboratories (2019): Pursuing Safety in Diagnosis and Treatment at the Intersection of Design, Systems Engineering, and Health Services Research (R18) RFA-HS-19-001

This project was supported by grant number R18HS027261 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

Editor: Sara Bayramzadeh Graphic Designer: Parsa Aghaei

Table of Contents

Overview 4

Literature Review 30

Case Studies 40

Focus Groups 50

Next Steps 56

Advisory Committee

62

Overview “Toward a Model of Safety and Care for Trauma Room Design” is a $2.47m grant project awarded by the Agency for Healthcare Research and Quality (AHRQ). It is a cross-disciplinary collaboration between Kent State University’s Healthcare Design, Nursing, and Computer Science programs and Cleveland Clinic Akron General. The project aims to help save patients’ lives by improving the design of Level I trauma rooms. Dynamics among people, technology, organization, tasks, and the physical environment of a trauma room will be studied. The project is a five-phase cycle (problem analysis, design, development, implementation, and evaluation). Goals of the project include developing design strategies to integrate technology and maximize future adaptability, testing proposed design strategies for a trauma room, and developing an evidence-based model for designing trauma rooms that support efficient patient care while maintaining a safe environment. The developed design guide model is expected to contribute to patient safety in trauma rooms by serving as a primary source to direct the design of the next generation of trauma rooms.

6

Overview • Budget: $2.47m for 4 years • Institutions:

Kent State University (Kent, OH)

Cleveland Clinic Akron General (Akron, OH)

SUNY (Canton, NY)

• Focus: Level I trauma rooms • Advisory Members: Texas, Michigan, South Carolina, Indiana

7

Sponsor Agency for Healthcare Research and Quality • Part of U.S. Department of Health and Human Services • The lead federal agency charged with improving the safety and quality of America’s health care system.

• Mission: to produce evidence to make health care safer, higher ..... quality, more accessible, equitable, and affordable.

Patient Safety Learning Laboratory • Systems engineering approach • Cross-disciplinary collaboration • Improve patient safety

8

......

Awardees Kent State University

Located in Kent, OH, Kent State University (KSU) is a public institution that enrolls approximately 42,000 students across eight campuses and offers more than 280 academic programs. KSU is the region’s first-choice public university and is the largest public multi-campus system in Ohio. The Healthcare Design Program, College of Nursing, the Department of Psychological Sciences, and Computer Science are the awardees from Kent State University.

Kent State’s Healthcare Design Program

The Master of Healthcare Design (MHD) is a post-professional master’s degree program and one of the few programs focused specifically on healthcare design in the United States. Evolving medical knowledge, technology, and delivery systems are constrained or liberated by design of healthcare settings in this rapidly growing sector. The MHD leverages applied research to transform healthcare design practice by pioneering healthcare design innovation and reinforcing human-centered solutions through both empathic and evidence-based design. KSU is located near Cleveland and Akron with access to several key healthcare systems, including Cleveland Clinic. Partnerships with regional healthcare systems uniquely position MHD to provide opportunities for transdisciplinary research and education.

Kent State’s College of Nursing

College of Nursing (CON) is accredited by the Commission on Collegiate Nursing Education and was re-designated as a Center of Excellence in the Science of Nursing Education for 2017-2022 by the National League for Nursing. Affiliated with more than 350 clinical partners, CON provides students with real-life experiences in clinical settings.

Cleveland Clinic Akron General

Founded in 1914 as Peoples Hospital, Cleveland Clinic Akron General (CCAG) is a nonprofit healthcare organization that serves as the hub for Cleveland Clinic’s Southern Region. CCAG has demonstrated its support for emergency and trauma care by building a $43 m state-of-the-art Emergency Department (ED). The ED is comprised of 60 treatment rooms including two trauma rooms, two resuscitation rooms, six rooms for minor injuries and illnesses, five behavioral health rooms, a rooftop helipad for urgent patients, an imaging department, a designated area for patients who are seeking treatment for sexual assault, and a designated area for quarantine and treatment of highly contagious patients.

9

The research team is led by the Principal Investigator project lead from Kent State University, Dr. Sara Bayramzadeh, and the project lead from Cleveland Clinic Akron General, Dr. Ali Mallat.

This project includes co-investigators, collaborators, and graduate research assistants from Kent State University, Cleveland Clinic Akron General, and the State University of New York.

Sara Bayramzadeh Ph.D., M.Arch.

Coordinator and Elliot Professor Healthcare Design Program

Mary K. Anthony Ph.D., RN Professor and Associate Dean for Research College of Nursing

R E S E A R C H T E A M

Douglas L. Delahanty Ph.D. Associate Vice President Research Faculty Development Professor of Psychological Sciences

Terri Stefanko Project Coordinator

Ali F. Mallat

MD, MS, FACS Executive Medical Director, Acute Care Surgery Associate Trauma Medical Director Chief of Emergency General Surgery Surgical Critical Care Director Assistant Professor of Surgery, Case Western Reserve University

Jessica Krizo

Ph.D. Research Faculty Emergency Medicine and Trauma Services

Steven Brooks

MD, FACEP Chairman Department of Emergency Medicine

Kambiz Ghazinour Naini

Ph.D. Assistant Professor, Center for Criminal Justice, Intelligence and CyberSecurity at SUNY in Canton Director of the Advanced Information Security and Privacy Lab

S T U D E N T S

Sahar Ahmadpour

Parsa Aghaei

Graduate Research Assistant Healthcare Design Program

Graduate Research Assistant Healthcare Design Program

Rachel Rebmann

Leong Yin Tanya Chiu

Faculty Assistant Healthcare Design Program

Graduate Research Assistant Healthcare Design Program

Hossein Mirzajani

MD Mazharul Islam

Graduate Research Assistant Healthcare Design Program

Graduate Research Assistant Healthcare Design Program

Hamid Estejab

Kayla O’Donnell

Graduate Research Assistant Healthcare Design Program

Honors Nursing Student

Zhengyong Ren

Madeline Sterling

Ph.D. Student, Research Assistant Computer Science Program

Maryam Ghasemian Ph.D. Student, Research Assistant Computer Science Program

Honors Nursing Student

?

Background Why Trauma Rooms?

Traumatic injuries account for 59% of deaths in individuals under 44 years old, and unintentional injuries are the third leading cause of death in the United States (CDC, 2016). Time is precious in the context of a traumatic injury, and patients need immediate help within the first hour of experiencing an injury (referred to as the golden hour), including a 10-minute critical period for resuscitation and stabilization in the trauma room to provide life-saving measures (Rogers, Rittenhouse, & Gross, 2014). Any delays or complications can result in suboptimal treatment or death. The first point of contact for a hospital with a traumatically injured patient occurs in the trauma room where a patient is initially stabilized. However, little research has been conducted regarding the impact of the design of this room on trauma team performance and patient safety and survival.

The role of environmental design to improve patient safety is evident, as the physical environment is one of the five critical components of the work system (organization, people, tasks, technology, and physical environment) as defined by the Systems Engineering Initiative for Patient Safety (SEIPS) model (Carayon et al., 2006). Each component is critical to achieve improved patient safety and care. The Advanced Trauma Life Support (ATLS) provides guidelines on improving trauma care itself (ACS-COT, 2013), but it does not encompass the fact that the components of the SEIPS model play a role in the strength and success of the trauma team. Although design of the environment plays a role in improving trauma team performance, little is known on how the design of trauma rooms achieves improved performance (Hicks & Petrosoniak, 2018).

13

Research Project Goals The proposed study uses a work system approach to investigate how the design of the physical environment can support patient safety by facilitating staff task performance and technology integration while reducing disruptions during Level I trauma events. This study will significantly contribute to the body of knowledge by developing an evidencebased design model for trauma rooms that support patient safety. This study is being developed as a transdisciplinary collaboration between Kent State University (KSU) and Cleveland Clinic Akron General (CCAG).

Goal 1: Identify factors related to the physical environment that influence patient safety and efficient care in trauma rooms. This aim centers on the adaptability of the physical environment to staff, patients, tasks, and technology integration in the trauma room.

Goal 2: Develop design strategies to address patient safety and efficient care and to integrate technology such that future adaptability is maximized.

Goal 3: Test proposed design strategies for a trauma room.

Goal 4: Develop an evidence-based model for designing trauma rooms that supports efficient patient care while maintaining a safe environment.

14

Project Timeline

Phase 4 Implementation

Phase 1 Problem Analysis

2023

2021

2019

2022

Phase 2 & 3 Design +Development

Phase 5 Evaluation

15

?

Project Foci

16

Workflow

Interruptions and Disruptions

Trauma resuscitations consist of serial and iterative assessments and procedures that require immediate action for diagnosing and stabilizing the injured patient (ACS-COT, 2013). In a high-risk, time-pressured, crowded, and complex environment, maintaining an efficient workflow can be a challenge. Workflow is a critical component of effective trauma resuscitation, as its inefficiencies may lead to adverse events and ultimately compromise patient safety (Petrosoniak et al., 2018).

Preventable errors contribute to 7-9% of deaths during patient resuscitation (Ivatury et al., 2008; Vioque et al., 2014). Interruptions are one type of preventable error, classified by the Joint Commission. An interruption is a break in the performance of an activity by either internal or external stimuli and can result in loss of concentration. Disruptions are events that hinder, pause, or compromise the normal workflow and threaten patient safety on various levels.

Physical Environment Factors:

Physical Environment Factors:

• Layout

• Room layout

• Adjacencies of different areas

• Room size

• Location of tasks

• Equipment integration

?

Project Foci Technology

Sensory Factors

Information processing in trauma resuscitation is complex, as it involves the five steps of observation, communication, decision making, re-communication, and intervention (Sarcevic, 2009). The observation phase feeds the information to the team and is of utmost importance because its accuracy is critical to the successful conduct of the remaining phases of information processing. In fact, inaccurate information and misuse of resources are classified by the Joint Commission as one of the preventable errors that lead to increased mortality (Vioque et al., 2014).

Sensory-related factors are those related to lighting, acoustics, and temperature. Lighting-related studies are scarce in trauma rooms. Some of the known issues in similar environments, such as ORs, include ambient light outside of the surgical field, shadow casting, and poor illumination quality, all of which contribute to inefficient performance among staff (Joseph, Bayramzadeh, Zamani, & Rostenberg, 2017). Although we were unable to find any literature concerning lighting issues in trauma rooms, anecdotal discussions with healthcare staff underscore that these issues are common in trauma rooms also.

Physical Environment Factors: • Information displays

Physical Environment Factors:

• Location and integration

• Lighting issues (e.g. glare) • Noise • Temperature maintenance

17

Framework This study uses the System Engineering Initiative for Patient Safety (SEIPS) model as the framework to guide the overall approach to conducting the project. The SEIPS model introduces five major components in a work system (organization, people, tasks, technology, and the physical environment) and their relationship with processes and outcomes. Our project explores the intersection of physical environment with technology, people, and tasks. The design of the physical environment can have significant implications for patient safety in unpredictable environments such as trauma rooms. Adherence to the SEIPS model will ensure the patient safety goals are achieved by improved design of the physical environment. We adapted the framework within the context of trauma rooms to address relevant issues as demonstrated in the SEIPS diagram.

18

SEIPS

System Engineering Initiative for Patient Safety Holden et al., 2013

Framework Care Pro ces s

People

The trauma team’s knowledge of injuries The medical needs of the patient Collaboration among team members

ie n t

Ef

fic

ty

C a re

En

Pa t i e n t S a fe

Te c h n olo g y

PHYSICAL ENVIRONMENT

Trauma room layout - positioning and proximity Adaptability, flexibility, and expandability Lighting, Noise, Temperature

f Sa Staf fety

Tasks

ORGANIZATION

Teamwork Coordination Supervisory Style

Peo p

le

TASKS

Cognitive Load Time Pressure Diagnosis Decision Making

al sic ment y n Ph iro v

tion niza a g Or

TECHNOLOGY

Information Displays Human Factors Characteristics (e.g. usability) Imaging Technology

I n fo r m

nF atio

lo w

19

5

Five Phases

Phase

01

• Literature Review • Preliminary Observations • Focus Groups • Case Studies • Systematic Observations

Problem Analysis

Phases

02&03 • Knowledge-based Symposium • Design Thinking Sessions • Preliminary Design Guidelines • Iterative Design Process • Developments - Studios • Evaluation - Augmented Reality • Refinement

Phase

04

• High-Fidelity Physical Mock-Up

Implementation

Phase

05

• Scenario-Based Simulation • Design Refinement • Evidence-Based Design Model

Design+Development Evaluation

20

Phase One Accomplishments Phase one of the project was aligned with the first goal of the project and focused on problem identification and analysis. Factors related to the physical environment that can impact safety and efficient care in trauma rooms were explored.

Patient Safety Learning Lab Establishment IRB Approval - IRB approval was obtained in September 2019 in accordance with human subject research requirements including activities related to focus groups.

Research Team Training - Training of the team members on research procedures was done.

Advisory Board - The advisory committee was formed. They met virtually with the research team to get to know the project and the team.

Problem Analysis Phase Systematic Literature Review – Systematic literature reviews were conducted on four topics of workflow, interruptions and disruptions, technology integration, and sensory stimuli. These reviews were in the context of trauma rooms as well as similar complex environments such as operating rooms and intensive care units.

Case Studies- Case studies were conducted through analyzing precedents presented by architecture firms. The case studies also included an in-depth analysis of the workflow in five selected trauma centers.

Focus Groups – A total of 21 focus groups with six trauma centers across the United States were conducted. A total of 67 trauma team members participated in the focus groups. The focus groups were conducted based on the four major foci of the research project.

21

Site Introduction Our Patient Safety Learning Lab is a collaboration between Kent State University and Cleveland Clinic Akron General’s Emergency Department. Cleveland Clinic Akron General has the only Level I trauma center across the Cleveland Clinic enterprise, which was built in 2018. This facility is the second Level I trauma center that serves adults in Akron, Ohio.

There are two trauma rooms in the emergency department. These rooms can expand to adequately treat two patients per room in the event of a mass casualty incident. Radiology, including computed tomography (CT), is located immediately outside of the trauma rooms for easy and rapid access.

Cleveland Clinic Akron General Level I Trauma Center 22

Site Introduction

23

Flow of Patient Care: Entering from Ambulance Entrance 01 Emergency Medical Services (EMS) contacts ED and EM physician determines activation level 1, 2, or 3

02 Overhead announcement and page of trauma activation level and ETA goes out

03 Trauma team members assemble in the trauma bay and prepare materials potentially needed based on patient information per EMS

04 Patient arrives via EMS

08 Secondary survey

07 Primary survey

06 Patient transferred to stretcher

05

09 Procedures

10 Patient receives imaging in trauma bay or CT in radiology suite

11 Patient leaves trauma bay (to OR, ICU, floor, or ER)

Start

EMS delivers MIST report (mechanism, injury, signs, treatment)

End

24

Flow of Patient Care: Entering from Emergency Department Main Entrance

Patient transferred to stretcher

01

Primary survey

02

Secondary survey

03

Patient leaves trauma bay (to OR, ICU, floor, or ER)

06

Patient receives imaging in trauma bay or CT in radiology suite

05

Procedures

04

Start

End

25

Diagram Zones In a trauma room, there are different groups of people who have different access to the patient depending on their responsibilities. There are three zones depending on the level of patient access needed. Zone 1 incudes people who need immediate access, such as the EM resident, EM attending, respiratory therapist, GS junior resident, nurses, technicians, and an advanced practice provider. Zone 2 includes people who need visual access to the patient, including a pharmacist, scribe nurse, primary nurse, trauma surgeon, and GS senior resident. Zone 3 includes staff who only need partial visual access and includes medical students, nursing students, trauma admin, and radiologist(s).

Immediate Access

Partial Visual Access

• EM Resident

• Pharmacist

• Medical Students

• EM Attending

• Scribe Nurse

• Nursing Students

• Respiratory Therapist • Primary Nurse

• Trauma Admin

• GS Senior Resident

• Radiologist

• GS Junior Resident • Nurses (2) • Technicians (2) • Advanced Practice Provider

26

Visual Access

• Trauma Surgeon

EM Resident Respiratory Therapist Float (RN) Nurse B GS Resident: Junior EM Tech A Trauma Surgeon Charge Nurse

Staff: Position

GS Resident: Senior Primary RN (Scribe) EM Tech B Trauma APP Pharmacist Float (RN) Nurse A EM Attending

General Surgery

Emergency Medicine

Pharmacy

Respiratory Therapy

27

EM Resident

Staff: Responsibilities

Assess and monitor airway Manage airway, Stabilize neck, Perform Neuro exam, HEENT portion of exam, FAST exam

Respiratory Therapist Airways adjuncts, Suctioning, Pulse oximetry, End Tidal CO2, Ambu, ABG’s

Float (RN) Nurse B 2nd IV, VS Administer blood products, Monitor and report status of IV fluids and blood products

EM Attending

GS Resident: Junior

Assume responsibility of the pt until arrival of the Trauma Surgeon, Supervise the EM Resident

Secondary Survey, Assist with procedures

EM Tech A Attach monitors, Initial vital signs, Warming methods, Measures/reports urine output

Float (RN) Nurse A IV/bloodwork, Obtain and administer meds as ordered, Assist with procedures, Warming methods, Assist in logrolling

Charge Nurse

Assist with coordination of patient care, Monitor crowd control

Pharmacist Provide dosage recommendations, Provide drug information

Trauma Surgeon GS Resident: Senior

Trauma APP Assist with secondary survey and procedures.

28

General Surgery

EM Tech B Assist with clothing removal, Transport the patient’s blood to POC

Emergency Medicine

Pharmacy

Team Leader, Direct & coordinate initial assessment, Resuscitation & stabilization of pt

Primary RN (Scribe) Overall supervision & delegation of nursing care, Document vital signs, primary & secondary survey and all care rendered

Respiratory Therapy

Assume care of patient upon arrival

EM Resident Respiratory Therapist Float (RN) Nurse B GS Resident: Junior EM Tech A Trauma Surgeon Charge Nurse

Staff: Mobility In a trauma room, some members of the medical team stay in one place, while others can move more freely throughout the room. For example, the pharmacist does not need direct access to the patient and can therefore move around the room. The EM Resident, however, needs to manage the airway and needs to stay by the head of the patient for the duration of the trauma resuscitation.

GS Resident: Senior Primary RN (Scribe) EM Tech B Trauma APP Pharmacist Float (RN) Nurse A EM Attending

Mobile

Stationary

29

Methodology

30

Literature Review

Case Studies

Focus Groups

Four independent review projects on four main project foci

Precedents and deep dive of six trauma centers

With trauma team members from six trauma centers

?

Research Questions 1. How can the physical environment support task completion, workflow, and efficiency?

2. How can the physical environment support staff by reducing crowding, interruptions, and disruptions?

3. How can the physical environment support patient safety through integrations with technology such that situational awareness and information sharing among staff are supported?

4. How can the physical environment support patient safety through regulation of sensory factors?

31

LITERATURE REVIEW

Literature Review Topics: Workflow

Disruptions & Interruptions

Technology

Sensory Factors

Goal: We conducted four independent systematic literature reviews on each of the four topics. The goal was to understand and identify the current status of scientific literature on how the design of trauma rooms impacts outcomes, such as workflow, interruptions, disruptions, sensory factors, and technology integration. We used databases such as PsycInfo, Medline, PubMed, CINAHL, and Web of Science to locate relevant empirical studies published in scholarly journals.

33

Literature Review: Workflow Abstract Efficacy of workflow within a stressful, time sensitive healthcare setting is imperative when it comes to patient care. The goal of this literature review is to investigate the impact of factors that either impede or enhance workflow within complex healthcare settings including trauma rooms, intensive care units, and operating rooms. PRISMA and MMAT guidelines were followed for reporting and quality appraising. From the 293 articles, 12 were eligible. Commonalities among the articles included congestion of workflow, disruptions, and accessibility. Factors impacting workflow included zoning, layout, and communication. Improved workflow will have positive outcomes when it comes to efficiency among staff and patient care.

Records identified through database searching and hand searches

Records after duplicates removed

n=

331 n=

293 n=

Studies included

34

12

Interaction

Adjacencies of areas

Understanding similarities in utilization of specific zones gives insight on the effect of OR layout design on CN performance.

Bayramzadeh et al.

2018

Sliding technology

Sliding gantry CT cut time in half compared to having two separate CT units.

Frellesen et al.

Operating room layout

Change in throughput was 2 additional patients per day.

Stahl et al.

2006

Ouctome

Outcome Category

Stimuli Type

2016

2015

Dual occupancy in NICU

Results showed increase in time spent communicating with other staff.

Safety & Efficiency

Ahmad et al.

Flow disruptions

Results showed that interruptions accounted for greatest number of disruptions.

Layout

Approximately half of the procedure-related movements were unavoidable. Although the movements are necessary, they can still be reduced by modifying the OR layout.

Efficiency

Robot-assisted procedures

Work patterns and flow disruptions

Room layout can significantly affect circulating nurse’s movement within the OR.

Broom et al.

2019

Cohen et al.

2016

Neyens et al.

2019

Literature Review: Interruptions & Disruptions Abstract Interruptions and disruptions are common occurrences in critical care environments, including trauma rooms, and are of concern for nurses who represent 47% of the hospital work force. The fast pace and high stress of patient care common in trauma centers, ICUs, and ORs presents ample opportunity for interruptions, leading to breaks in care.

This literature review focused on how factors of the built environment affect workflow disruptions and interruptions of nurses and both the positive and negative outcomes on patients. We collected existing empirical literature on interruptions and disruptions in complex care environments and organized it according to the Systems Engineering Initiative for Patient Safety model to summarize and identify the effects on patient care and workflow. The systematic literature review was conducted using PRISMA guidelines.

CINAHL, Web of Science, EBSCO, and PubMed were searched. Duplicates were removed, and remaining articles were screened for eligibility. Mixed Methods Appraisal Tool (MMAT) guidelines were used to conduct the quality assessment. After the search was completed, 1,159 total articles resulted. Several rounds of screening resulted in 39 articles; 21 articles remained after MMAT quality screening. Cohen’s Kappa for inter-coder reliability was 0.62. Most of these studies were located in ORs (13), followed by ICUs (6) and Level 1 Trauma rooms (2). Of the 21, 20 were quantitative (16 descriptive and four nonrandomized). There was one mixed-method study. Interruptions and disruptions in relation to the physical environment were most often related to layout, equipment, and communication deficits. Studies reporting patient or staff outcomes were mostly related to delayed or missed care. Studies on trauma rooms were limited, and future studies need to focus on this type of setting further.

36

Records identified through database searching

Records after duplicates removed

n=

1159 n=

874 n=

Records screened

21

OR

ICU

OR

OR

OR

OR

Trauma Room

OR

Stress and fatigue, and therefore errors, can be the result of the surgical team being interrupted or disrupted.

Interruptions and disruptions cause medication errors.

“Intraoperative interruptions potentially interfere with surgical flow, contribute to patient safety risks, and increase stress.”

Interruptions and disruptions cause compromised patient safety, decreased efficiency, longer travel distance and time and communication outcomes.

Integrated ORs did not result in a reduction in equipment-related surgical flow disturbances.

Increase in error/critical incidents during surgical performance are caused by interruptions and disruptions.

Al-Hakim et al.

2019

OR

Medication errors, incomplete tasks, and gaps in care continuity can result from interruptions.

OR

Interrupted surgical teamwork.

OR

Interruptions and disruptions hinder physician performance.

OR

Interruptions and disruptions cause higher stress, higher perceived workload for surgical staff, increased surgery duration, surgical errors, and increased patient mortality.

OR

In industrialized countries, 3–16% of inpatients experience major surgical complications, with mortality between 0.4% and 0.8%.

Neyens et al.

ICU

Interruptions can cause errors that result in decreased patient safety.

Prates et al.

ICU

“The effect of different types of interruptions on task performance cannot be inferred from the data.”

Trauma Room

“The effect of different types of interruptions on task performance cannot be inferred from the data.”

Shouhed et al.

ICU

Interruptions cause error and patient harm.

Spooner et al.

OR

Interruptions can affect staff communication, surgeons’ attention, patient care, and team coordination and efficiency.

Weigl et al.

OR

Loss of concentration, and therefore risk of error, was increased due to continuous interruptions.

Yoong et al.

2010 Antoniadis et al.

2013 Bayramzadeh et al.

2018 Blikkendaal et al.

2017 Campbell et al.

2012

Catchpole Targeted interventions could help reduce interruptions and disruptions caused by equipment et al. issues, patient factors, coordination and communication, and leadership and teamwork.

2014

Flow disruptions increase the likelihood of surgical errors and mental workload.

Interruptions affect human performance.

Anthony et al.

Cohen

Ouctome

Context

Outcome Category

Theme

ICU

2019

Goras et al.

2019

Healey et al.

2006

Healey et al.

2007

Joseph et al.

2019

2018

2016

Sasangohar et al.

2014

et al.

2016

Correlations exist between interruptions and patient morbidity and mortality, workflow inefficiency, documentation and medication errors, reduced patient satisfaction, and increased healthcare costs.

Drews et al.

ICU

Craker et al.

2017

2013

2019

2015

2015

Literature Review: Technology Abstract To support safety and efficient care, effective integration of technology into timepressured, high-risk healthcare environments is critical. This systematic literature review aimed to highlight the impact of technology on the physical environment as well as the facilitators for and barriers to technology integration into complex healthcare settings, including operating rooms and trauma rooms. PRISMA and MMAT guidelines were used for reporting and quality appraisal. Out of 1,001 articles, 20 were eligible. Identified categories included hybrid and integrated environments, technological ambiance, and information technologies. Technology integration has implications for direct patient care, efficiency, throughput, patient safety, teamwork, communication, and the perception of care. The facilitators for and barriers to technology integration included layout design, equipment positioning, and decluttering. The physical environment can improve the impact of technology on factors such as patient safety and efficiency.

Citation Bayramzadeh, S., & Aghaei, P. (2021). Technology integration in complex healthcare environments: A systematic literature review. Applied ergonomics, 92, 103351.

38

Records identified through database searching and hand searches

Records after duplicates removed

n=

1122 n=

1001 n=

Studies included

20

ICU

Patients who are in critical conditions perceive technologically intense environments as intimidating.

Almerud

ICU

Educating people on the way equipment works can result in their acceptance of the technological environment.

Locsin et al.

CCU

It is important for nurses to maintain the human touch associated with the nursing practice to keep patients feeling cared for.

McGrath

ICU

Proper lighting should be enforced to mimic the natural circadian rhythm to maintain the quality of sleep for patients.

2007

2013

Merilainen et al.

2010

ICU

Participants endure technological equipment as they find it necessary for their care despite not being fond of it.

Stayt et al.

Technology saves nurses time on reports which allows them to spend more time on patients and diagnosing their problems.

Tunlind

Where a single sliding CT scanner was being used for the trauma room, average time to CT was 15 minutes, and average time to get the patient admitted to the OR was 96.5 minutes.

Hybrid Settings

2008

ICU

Context

Outcome Category

et al.

Olausson

Trauma Room

Safety

2016

Hallucinating patients can find the environment intimidating. The other patients who are in pain can negatively affect a patient in distress.

ICU

Theme

et al.

et al.

Safety

2013

2015

2015 Kippnich et al.

2020

OR

The arrangement and layout of the equipment affects healthcare providers’ ease of working.

Pennathur et al.

2013

Trauma Room

89% of trauma patients are transferred to the imaging department. Lack of the equipment in the Blocker et al. trauma room results in disruptions, 17% of which 2013 result in full cessation or moderate delays.

Trauma Room

The addition of CT imaging devices to trauma rooms allows for more precise decisions.

Trauma Room

In patients with traumatic brain injury, those who were treated in a hybrid ER showed 14% less adverse outcomes compared to patients treated in a traditional ER.

OR

In the integrated OR, monitors placed on a ceiling-mounted boom arm should only be placed when it is not a source of disturbance to the OR team.

OR

Acknowledgment of the equipment and its price can remedy patients in dealing with the technologically intense hybrid OR and make them feel special.

OR

Using a dual-room setting can mitigate the cost of a hybrid OR while not having a significant impact on the procedures’ timing or creating space issues.

Frellesen et al.

2015

Kinoshita et al.

2018

Blikkendaal et al.

2017 Bazzi et al.

2020

Lenski et al.

2019

Chen et al.

2011

The average time to CT was not significantly different with the implementation of a mobile CT scanner.

Wulffeld et al.

2017

ICU

Integration of a large customizable interactive monitor can be beneficial for keeping the people accompanying the patient in the loop and making the data more accessible.

Asan et al.

2018

ICU

Using a large customizable interactive monitor should not contradict patient privacy despite being HIPAA compliant; proper positioning of the device could help this objective.

Asan et al.

2017

Trauma Room

et al.

Information Technology

Perception of care and treatment quality

OR

Ouctome

Robotassisted procedures Technological Environment

Efficiency

Ahmad

Where possible, wireless technology should be used instead of wired.

Literature Review: Sensory Factors Abstract This systematic literature review aimed to: (1) explore outcomes resulting from sensory stimuli in the complex healthcare environment that hosts patients with vulnerable conditions; and (2) identify physical environment interventions that impact sensory stimuli. PsycInfo, PubMed, and Web of Science databases as well as a hand search were used to collect articles. Two research members screened articles for eligibility based on the PRISMA model. MMAT guidelines were used for quality appraisals. We identified 30 eligible articles out of 1,118. Noise, lighting, and temperature were the major categories explored, and the results showed that their impact on staff and patients can manifest in forms of physiological outcomes, psychological outcomes, and neurological outcomes.

Noise, for example, has and impact on sleep quality and staff performance. Room size, room layout, room location, open ward versus private room, natural and artificial lighting, materials, and finishing were environmental interventions that influenced sensory stimuli in units. The results showed that the number of studies on issues related to sensory stimuli, particularly in the context of trauma rooms, is few. Further, few articles studied the impact of sensory stimuli on staff. This literature review guides the next steps for future studies on sensory stimuli in complex healthcare environments.

40

Records identified through database searching

Records after duplicates removed

n=

1118 n=

820 n=

Records screened

30

Nannapaneni et al.

2015

ICU

Environmental noise, psychological factors, and a sense of restriction cause stress in the ICU.

Heidemann et al.

2011

ICU

Avoiding redundant procedures at night, as well as the use of earplugs, reduces noise-related stress among patients.

ICU

High noise levels have negative impacts on nurses’ extrinsic satisfaction. Nurses’ intrinsic satisfaction was higher than extrinsic satisfaction.

ICU

Sound levels were extremely high in the ICU, but there was no statistical relationship between early signs of ICU delirium and high sound levels.

ICU

Less exposure to sunlight before critical illness leads to a better outcome.

ICU

Inadequate daylight exposure may impact patients’ circadian rhythm, but nighttime light did not affect melatonin secretion.

ICU

Environmental factors can decrease stress, burnout, and medical error, and increase nurse satisfaction and resident mood in inpatient units.

Neurological outcome

Outcome Category

Stimuli Type

Psychological outcome

Context

Light

Physiological outcome

Czaplik et al.

2019

ICU

Age, severity of illness, and dexmedetomidine had an impact on delirium occurrence among patients.

Environmental design

ICU

White noise is recommended to mask environmental noises and improve and maintain sleep.

Afshar et al.

2016

ICU

There was no relationship between the ICU environment and patients’ sleep quality. The quiet routine protocol could not reduce the existing low noise levels in the ICU.

Boyko et al.

2017

ICU

Noise and light reduction, patient comfort, patient care activities, and uninterrupted time for adequate sleep improve patients’ sleep quality.

Eliassen & Hopstockb 2011

ICU

Guidelines for controlling night-time noise and care activities and reducing external noise levels improve patients’ sleep quality.

Li et al.

2011

Psychological outcome

ICU

Healthy participants encountered sleep disruption in the ICU. The frequency of interruptions in staff sleep time was less than the patient’s sleep disruption.

Reinke et al.

2019

Psychological outcome

ICU

Turning the lights down at “quiet time” significantly reduced nurses’ stress level, but did not significantly impact the noise level.

Reimer et al.

2015

ICU

Staff members have limited knowledge about noise and sound in patients’ rooms.

Johansson et al.

2016

ICU

Design interventions reduced noise levels, promoted a day-night pattern, and decreased peak levels.

Luetz et al.

2016

ICU

Single-patient rooms and noise-reducing strategies can be effective in controlling environmental noise in the ICU.

Kol et al.

2015

ICU

Noise levels were lower in the single bedroom, and about 64% were avoidable.

Tegnestedt et al.

2013

Noise and Light

2016

Terzi et al.

Neurological outcome

Environmental design

Johansson et al.

2012

Castro et al.

2012

Fan et al.

2017

Gharaveis et al.

2020

Noise

Psychological outcome

2012

Light

ICU

The noise level’s mean did not change significantly after implementing systemlevel changes, education, and patient-level interventions.

Xie et al.

Noise

Intrusive noises were more likely to happen in multi-bed wards, and extreme sound in single bedroom wards.

White

ICU

Ouctome

Noise

Environmental design

Environmental design

Estrup et al.

2018

CASE STUDIES

Case Studies Case studies were conducted through presentations made by architecture firms on select trauma room and emergency department design projects.

Further, six Level I trauma centers were studied in-depth and analyzed for barriers to and facilitators for workflow, five of which are presented here.

43

Precedents: Perspectus Architecture

Cleveland Clinic Fairview Hospital, Level II Trauma Room, Fairview Park, OH

44

Architecture Firm: Perspectus

Organization Factors

Technology

People

Physical Environment

Physical Environment

Branding Implementation

Constant Technological Evolution

Staff Preparedness

Support Areas’ Location

The Importance of User Involvement

Many facilities design around their own branding. Cleveland Clinic uses white with grey floors, which is intended to communicate cleanliness, high technology, and a focus on care. Even though the rooms look plain, aesthetics are discussed significantly. In areas such as patient room headwalls, they use high impact wall protection to endure extensive use, which can look different.

However, they used color to blend it in with the overall room. From a healthcare standpoint, people are in the environment for 12-hour shifts, so choice of color should be thoughtful as well, which can be a challenge if it conflicts with branding.

The Importance of User Involvement Working closely with users and interacting with a mock-up informed the design process.

The biggest challenge with technology is the constant evolution over time. Thus, providing flexibility is important to allow accommodation of technology.

Examples include the connections for the monitors and workstations, having plenty of locations for power in case something needs to be plugged in, and plenty of Wi-Fi coverage, since a growing number of equipment are using Wi-Fi.

Adequate Electrical Receptacles A rarely noticed element, which is of importance, was that the electrical receptacles used were quad receptacles, due to the high demand and an assumption that duplexes would not be adequate.

However, many types of equipment come with a receptacle that is very large and blocks the rest of the receptacles. Thus, instead of using quads, the team implemented multiple duplexes to have a better opportunity to plug in equipment and devices.

The teams are usually aware of patients’ status and incident details before they arrive, as they receive the information from the ambulance or helicopter crew and know what’s coming. The only challenge with preparedness is when a patient is dropped off by a car without much prior information.

With the Staff in Mind Considering staff work when designing and allocating spaces around the trauma room is important.

Tasks Cleanability The ability to clean surfaces and objects well and easily is very important. This can be accomplished by minimizing corners and joints in materials, for example.

Outside the trauma room, several spaces act as supporting areas, including workstations, respite rooms/restrooms, consult rooms, and equipment alcoves. The location of these areas is important.

Having a full workstation directly across the room proved innovative.

Oftentimes trauma rooms are far away from nurse stations, so having a dedicated workstation directly outside is helpful. Having a consult room, a staff respite room, and restroom nearby to allow them to take a break in between cases is beneficial. Having an equipment alcove across the hall helps with decreasing clutter and improves easy access. Further, the ambulance bays were designed for decontamination (e.g., in industrial accidents) and are under a canopy cover. A grommet system in the base of that canopy was designed, and storage for large curtains and showerheads was provided.

This allows for a very large decontamination area. The heating elements in the ceiling bring the temperature up in that area.

Flexibility In trauma rooms, flexibility is key.

Therefore, all the elements of the room, except for the fixed storage, were mobile and on wheels, which worked well for staff. Despite questions around clutter, staff seemed to easily organize all elements after each case.

Having a support room, which included storage and a sink, between two trauma rooms was unique and offered them the ability to store things outside the room.

The storage includes PPE. The space allows staff to use the sink and don and doff without being in other people’s way.

Having the bed in the center of the room pointing perpendicular to the hallway is the best setup from a staff access standpoint.

It provides ample visibility for someone entering the room and provides easy and quick access to either side of the patient depending on where the injury is. The bed maintains about two feet of distance from the wall to allow staff to access all four sides of the patient. Without having any place that the bed locks into position gives them the flexibility to move the patient around as necessary. The guidelines indicate that there should be a minimum of five feet on all sides of the bed and 10 feet between each bed if multiple patients are in the room. The ability to provide more space at the head wall allows for intubation, a respiratory therapist, an anesthesiologist, and even a surgery, when needed.

Precedents: IKM Architecture

University of West Virginia Medicine, Emergency Department, Morgantown, WV

46

Architecture Firm: IKM Architetcure

Organization Factors Institution’s Goals To design effectively, understanding the culture of the healthcare organization is important. It is normal to see that often there is resistance to change. This has implications for design and its intended goals. Such understanding includes the micro-culture of the specific institution (e.g., operations) and how people work with each other (e.g., who they are, how they relate to each other at the team stations and in the trauma room).

It is crucial to understand how staff want their processes to work.

The Importance of User Involvement Involving users helped them understand the current workflow and what would work better for them. Their involvement helped make informed design decisions that did not result in a lack of clinical care.

It is important to know details such as who stands where and what supplies they need. They mapped out the room in terms of “we put it there because we didn’t have any other space for it” or “we put it here because this is the exact right place for it”. This allows the design team to prioritize the organization of the room and the activities that take place.

Iterative Design Evaluation A design iteration will allow for making mistakes early, which is crucial as it enables the design team to come up with solutions and keep track of the decisions and their implications, and prevent impacting the overall project.

Making a 3D model early helps with identifying ineffective design decisions and helps everyone to understand the limits and parameters and to understand the room in a way that they otherwise would not have. A mock-up of the room on-site allowed staff to comprehend the design and share feedback. A pre- and postoccupancy survey can clarify what elements and characteristics worked for staff.

Technology Technology Integration Integration of lights and booms requires a high level of coordination, and teams should be mindful of choosing the most appropriate technology from a large pool of those available on the market (e.g., wallmounted computer vs. wireless technologies).

People

Physical Environment

Physical Environment

Staff Being a Priority

Support Areas’ Location

The Importance of User Involvement

Trauma rooms have less to do with patient experience (because of the state of the patient), and more to do with helping clinicians facilitate care (helping them to have shorter travel distances and better lighting, and making their day as easy as possible).

People Present Many people, including team members and those who are not part of the team, move in and out of the trauma room all the time. Examples of nonmembers include students and security staff. This can cause issues related to crowding and disruptions.

Outside the trauma room, several spaces act as supporting areas, including workstations, respite rooms/restrooms, consult rooms, and equipment alcoves. The location of these areas is important.

Having a full workstation directly across the room proved innovative.

Oftentimes trauma rooms are far away from nurse stations, so having a dedicated workstation directly outside is helpful. Having a consult room, a staff respite room, and restroom nearby to allow them to take a break in between cases is beneficial. Having an equipment alcove across the hall helps with decreasing clutter and improves easy access. Further, the ambulance bays were designed for decontamination (e.g., in industrial accidents) and are under a canopy cover. A grommet system in the base of that canopy was designed, and storage for large curtains and showerheads was provided.

This allows for a very large decontamination area. The heating elements in the ceiling bring the temperature up in that area.

Flexibility In trauma rooms, flexibility is key.

Therefore, all the elements of the room, except for the fixed storage, were mobile and on wheels, which worked well for staff. Despite questions around clutter, staff seemed to easily organize all elements after each case.

Having a support room, which included storage and a sink, between two trauma rooms was unique and offered them the ability to store things outside the room.

The storage includes PPE. The space allows staff to use the sink and don and doff without being in other people’s way.

Having the bed in the center of the room pointing perpendicular to the hallway is the best setup from a staff access standpoint.

It provides ample visibility for someone entering the room and provides easy and quick access to either side of the patient depending on where the injury is. The bed maintains about two feet of distance from the wall to allow staff to access all four sides of the patient. Without having any place that the bed locks into position gives them the flexibility to move the patient around as necessary. The guidelines indicate that there should be a minimum of five feet on all sides of the bed and 10 feet between each bed if multiple patients are in the room. The ability to provide more space at the head wall allows for intubation, a respiratory therapist, an anesthesiologist, and even a surgery, when needed.

Case Studies Workflow Analysis Because traumatic injuries are one of the leading causes of death in the United States, Level I trauma centers are prepared to treat the most severe cases of trauma to reduce the mortality rate. Therefore, the work conducted in trauma rooms is of utmost importance. The sensitive nature of operations in trauma rooms requires fast responses and seamless workflow for staff to achieve efficient care and save patients’ lives.

We conducted case studies of six Level I trauma centers across the United States. The case studies identified and assessed factors related to the physical environment that can influence workflow.

Our case studies highlight how the physical environment can be a barrier to or facilitator for workflow.

Our case studies also highlighted that the physical environment is associated with other components of the SEIPS model, such as technology, tasks, and people in its impact on workflow. Some examples of factors that enhance or impede workflow are layout design, appropriate room size, doors, sink locations, access to resources such as x-ray or blood, and access to technology.

48

Case Study #1 Location: Georgia Layout: Enclosed Room Room size: 280 sq.ft

Barriers to workflow Boom as obstruction

1

Facilitators for workflow 1 Mobile computer 2 Adequate storage space 3 Clearly labeled supplies

Doors not large enough

2

4 Sink adjacent to door

49

Case Study #2 Location: New York Layout: Semi-Open Room Room size: 328 sq.ft

Barriers to workflow Floor-mounted equipment as obstruction

1

Ceiling-mounted x-ray machine as obstruction

2

Poor crowd control in semi-open room

3

Facilitators for workflow 1 Designated areas for different items 2 Easy access to PPE and lead aprons 3 Storage for patient items

4 Access to hand sanitizer

50

Case Study #3 Location: Ohio Layout: Enclosed Room Room size: 741 sq.ft

Barriers to workflow Locked cabinets

1

Unreachable equipment

2

Facilitators for workflow 1 Disaster capacity

2 Movable cabinets and storage carts 3 Sink inside the room

51

Case Study #4 Location: Texas Layout: Enclosed Room Room size: 415 sq.ft

Barriers to workflow

52

Movable equipment gets in the way

1

Boom as obstruction

2

Non-optimal computer location

3

Poor sink location

4

Poor quality doors

5

Limited movement with small rooms

6

Poor layout creates congestion

7

Facilitators for workflow 1 Disaster capacity 2 In-room x-ray capability 3 Access to hand sanitizer

Case Study #5 Location: Ohio Layout: Enclosed Room Room size: 510 sq.ft

Barriers to workflow

Facilitators for workflow

Larger room attracts crowds

1

1 Disaster capacity

Unequal access to supplies

2

2 Ideal room size 3 Room well laid out

Boom with limited movement

3

4 Boom with wall suctions

Boom as obstruction

4

5 Easily articulated boom

Locked cabinets

5

Unreachable height

6

Broken automatic doors

7

6 Mobile computer 7 Clearly labelled supplies 8 Cabinets in good location

53

FOCUS GROUPS

Focus Groups To understand the experience and needs of trauma team members including physicians, surgeons, pharmacists, technicians, residents, and nurses, six facilities were selected for a focus group study. Each focus group included various roles within a trauma team to allow for a rich discussion on competing needs of the members. Focus groups were held online, were one hour long, and included semi-structured questionnaires. A total of 21 focus groups with 69 participants were conducted. Each focus group was focused on one set of research questions related to workflow, interruptions and disruptions, technology, and sensory factors.

21

Sessions

69

Participants

15

Roles

55

Focus Groups: Interruptions & Disruptions Challenges

56

Crowding

Presence of people who are external to the trauma team causes unnecessary noise and congestion

Glare

Glare causes difficulties in seeing x-ray results, for example, and should be reduced.

Door Openings

In trauma rooms, staff constantly open the doors to retrieve items from outside, transfer patients and equipment, and have other people come in. Door openings can cause distractions.

Missing Items

Not allocating specific locations to supplies or equipment and having mobile equipment can result in missing items, which can waste time and compromise a timely care procedure.

Missing Information

It is not uncommon to misunderstand or not receive information when the room is noisy.

Opportunities Consistent Placement

Placing equipment and supplies in designated spaces and keeping the storage locations stocked helps prevent missing items.

Zoning of the Room

Improving proximities of key areas within the room by modifying the layout can improve workflow and prevent disruptions.

Focus Groups: Workflow Challenges Poor Layout

Layout configuration defines paths of travel within the room. To increase efficiency and reduce time spent walking.

Inaccessible Equipment

Equipment should be in an easily accessible location and accessible height.

Poor Location for Storage Area

Storage areas that are far from staff who need the stored items can hinder workflow.

Blocked Sightlines from the Charting Station to the Room

The scribe nurse who uses the charting station should be able to see the room as easily as possible. Any visual obstructions will hinder the ability to receive correct information about the care procedure.

Opportunities Improving Proximity of Nursing Stations

Having a nursing station near trauma rooms supports workflow.

Accessible Location for Technology

Technology and equipment should be easy to access and easy to use to allow uninterrupted workflow.

Adequate Equipment Storage

Adequate storage allows for supplies to be available in the room as necessary.

Allocating Areas for Families

Families of trauma patients should be considered, whether they are near the room to see their loved ones or waiting outside the room in a consult room.

57

Focus Groups: Technology Challenges

58

Opportunities

Malfunctions

Infrequent maintenance of equipment has caused equipment like lights and CTscanners to malfunction.

Layout

Documenting nurse needs the computer facing the patient.

Educational Tool

Utilizing cameras instead of having students in the already crowded room for educational purposes is desired.

Underutilization

UV lights take a long time to decontaminate the trauma room and are therefore not utilized in trauma rooms.

Wireless Technologies

Many pieces of technological equipment used cords and wires for connectivity; wireless devices would remove the clutter of cords.

Learning Curve

Complex novel technological equipment requires additional trainings and takes time for staff to get used to.

Autonomous Information Management

Clarifying people’s roles on the displays was suggested by multiple participants.

Communication Tool

Projecting equipment with small screens onto big displays for better visibility is desired.

Focus Groups: Sensory Factors Challenges Crowding

Presence of people who are external to the trauma team causes unnecessary noise and congestion.

Temperature fluctuations

In trauma rooms, staff constantly open the doors to retrieve items from outside, transfer patients and equipment, and have other people come in. Door openings can cause temperature fluctuations.

Noise Levels

Trauma care requires quick exchange of information and when simultaneous, it increases noise levels. Constant beeping of the equipment adds to the noise levels in the room.

Poor Lighting

The inability to adjust the intensity or conditions that cause glare are problematic, as different procedures require an adjusted light intensity (e.g., reading x-ray results requires dimmed lights, but procedures require increased light intensity.

Opportunities Silencing Alarms

Most equipment do not allow silencing of the alarms for more than a few seconds, therefore providing staff with equipment that allow them to silence the alarms as they need can help with noise levels.

Incorporating Noise-Cancelling Materials

The type of materials used in trauma rooms should help reduce noise and echo in the room.

Adjustable Lighting

Given the staffs’ needs for different light levels throughout the trauma care, providing easily adjustable lighting becomes essential for an efficient workflow.

59

ADVISORY COMMITTEE

Advisory Committee An advisory committee was formed to support the research team from a scientific perspective. The advisory committee members include experts in the fields of systems engineering, trauma and acute care, and architecture.

They have been involved in the problem analysis phase as well as the design and development phases by providing feedback in the context of crossdisciplinary discussions.

61

Advisory Committee Jon Huddy, M.Arch.

President and Senior Healthcare Consultant, Huddy HealthCare Solutions Jon Huddy began his career in healthcare architecture and design in 1985 and served in numerous high-profile positions with firms across the US before establishing Huddy HealthCare Solutions, LLC in 2014. While continuing to deliver master plans worldwide, Huddy started focusing on emergency departments in the 1990s after earning a Master of Architecture in Health Facility Planning and Design and creating a specialized ED consulting team that delivered strategic planning, data analytics, operational process improvement, computer simulation, market analytics, master planning, and architectural design consulting. Throughout his career, Huddy has teamed with hundreds of healthcare organizations and 250 architectural, engineering, and construction firms in the US, Canada, South America, Europe, Middle East, and Australia to deliver high-performance facility designs. He has published numerous articles on high-performance healthcare planning; is the most sought after ED design consultant in the world; was selected by the American College of Emergency Physician to author ED Design: A Practical Guide to Planning for the Future; and launched the ED SizeIt app for Apple and Android.

62

Advisory Committee Richard Holden, Ph.D.

Associate Professor, Department of Medicine Indiana University, Chief Healthcare Engineering, Center for Health Innovation and Implementation Science Richard J. Holden is a human factors engineer and social-cognitive psychologist specializing in the domains of health and healthcare. He received a joint PhD in industrial engineering and psychology from the University of WisconsinMadison in 2009. Dr. Holden’s work applies human factors engineering and psychology to study and improve the work performance of patients, informal caregivers, and clinicians. He has investigated multiple healthcare interventions, including information technology, team-based care, and lean process redesign and has been supported by grants from the National Institutes of Health, Agency for Healthcare Research and Quality, Patient Centered Outcomes Research Institute, and other federal agencies. Dr. Holden has authored many scholarly works in the fields of human factors, patient safety and quality, biomedical informatics, and research methods. Dr. Holden is on the faculty of the Indiana University School of Informatics and Computing, Indianapolis, and is the Director of the Health Innovation Laboratory.

63

Advisory Committee Lena M. Napolitano

Massey Foundation Professor of Surgery, Founding Division Chief, Division of Acute Care Surgery, Director, Surgical Critical Care, Associate Director, Michigan Center for Integrative Research in Critical Care, Division of Acute Care Surgery Department of Surgery, University of Michigan Health System, Michigan Medicine Dr. Lena M. Napolitano is the Massey Foundation Professor of Surgery at the University of Michigan Hospital and Co-Director of Surgical Critical Care. Dr. Napolitano is certified by the American Board of Surgery in General Surgery and Surgical Critical Care. She is a Fellow of the American College of Surgeons, the American College of Critical Care Medicine, and the American College of Chest Physicians. Dr. Napolitano has served as a Director of the American Board of Surgery. She is also a past Chair of the Board of Governors of the American College of Surgeons and previously served as Secretary and member of the Executive Committee. She is a member of the Trauma, Burns, Critical Care Component Board of the American Board of Surgery, representing the American Association for the Surgery of Trauma. She has served on the AAST Board of Managers and Chaired the AAST Critical Care Committee and the Education Committee, and as a member of the Steering Committee of the U.S. Critical Illness and Injury Trials Group.

64

Advisory Committee Ryan P. Dumas, M.D.

Assistant Professor, Division of General and Acute Care Surgery, Department of Surgery, The University of Texas Southwestern Medical Center at Dallas Ryan P. Dumas, M.D., specializes in acute care surgery with a focus on trauma resuscitation and emergency general surgery. Dr. Dumas earned his medical degree at the Indiana University School of Medicine. He completed a residency in general surgery at UT Southwestern and received advanced training in trauma and surgical critical care through a fellowship at the John Paul Pryor Shock Trauma and Resuscitation Center at Penn at the Hospital of the University of Pennsylvania. Board certified in both surgery and surgical critical care, he joined the UT Southwestern faculty in 2018. Dr. Dumas conducts and publishes research on trauma surgery, particularly on procedures that use video technology to capture and review trauma resuscitations. Additionally, he has a special interest in the use of endovascular techniques for adjunct hemorrhage control.

65

NEXT STEPS

Next Steps In phase one of the project, the patient safety learning lab focused on developing a knowledge base through a deep dive into the existing literature, case studies, and focus groups. The research conducted helped identify the problems associated with trauma rooms, safety, and efficient care.

Next steps of the project include phase two and phase three, which are focused on design and development. A graduate studio in Kent State University’s Healthcare Design program was dedicated to designing a level I trauma room.

The research continued with brainstorming sessions with Master of Healthcare Design students and clinicians. Students built a full-scale physical mock-up of a trauma room, which is designed based on the research conducted in phase one. The mock-up will be used for scenario-based simulations to evaluate the proposed design strategies derived from research. To further the analysis objectively, observations of Cleveland Clinic Akron General’s trauma room will be conducted through a confidential platform. The observations will assess the variables of interest within the physical environment.

67

Next Steps Staff Journey Maps

By conducting a series of interviews with clinicians, the journey maps are created. They indicate the processes that each trauma team member conducts during a trauma case.

Design Thinking Sessions

The design thinking sessions help develop design ideas in a collaborative effort between healthcare design students and clinicians who have firsthand experience.

Trauma Room Design Studio

A design studio in the Healthcare Design program at Kent State University is dedicated to the design of the trauma room as part of this research project.

Low Fidelity Mock-Up Construction

A full-scale cardboard mock-up helps clinicians and researchers understand the trauma room design and creates opportunities for conducting simulations.

68

Next Steps Scenario-Based Simulations

Scenario-based simulations are conducted by clinicians. The three frequent types of trauma cases included in this study are a fall, a gunshot, and a car accident.

Augmented Reality Simulations Augmented Reality will provide a unique opportunity to develop prototypes and evaluate them in an efficient way. This phase will help with the design, development, and evaluation phases. It will also pioneer a new approach to design evaluation in the field of healthcare design.

Trauma Observations

Trauma observations will offer deeper insight into the barriers and facilitators in the trauma room.

Design Refinements

The team will continue to refine the design based on the results of evaluation sessions through scenario-based simulations and augmented reality user experience.

69

Acknowledgment This multi-year research collaboration on trauma room design aspires to help serve one of the most vulnerable patient populations whose struggle can be as extreme as life or death in a short window of time. The first year of this project coincided with the COVID-19 pandemic, creating an unprecedented experience for the scientific community. It disrupted the timelines and research methodologies planned for many research projects, and ours was not an exception. Despite the new challenges, we took this as an opportunity for innovation that is required to overcome adversity.

Throughout this journey, we have had support from various entities and individuals. We are very grateful to the Agency for Healthcare Research and Quality for sponsoring this research and continued support of the research projects during the COVID-19 pandemic. Their support for the Patient Safety Learning Labs is indeed an innovative approach for development of new knowledge that pushes the boundaries of science as well as implications for practice. We are thankful for the dedication of our graduate research assistants, students, and faculty who have been involved in this project. We thank our advisory committee members for their time and efforts to support the project on various levels. We have had support from many clinicians across the country who generously shared feedback and showed enthusiasm for this project. We are grateful to the Dean of the College of Architecture and Environmental Design, Mark Mistur, for his ongoing support of the project and its complex logistics.

Sara Bayramzadeh, Ph.D., M.Arch.

Coordinator and Elliot Professor in Healthcare Design Program College of Architecture and Environmental Design Kent State University

70

References Ahmad, N., Hussein, A. A., Cavuoto, L., Sharif, M., Allers, J. C., Hinata, N., Ahmad, B., Kozlowski, J. D., Hashmi, Z., Bisantz, A., & Guru, K. A. (2016). Ambulatory movements, team dynamics and interactions during robot-assisted surgery. BJU International, 118(1), 132–139.

Al-Hakim, L., Wang, M., Xiao, J., Gyomber, D., & Sengupta, S. (2019). Hierarchical task analysis for identification of interrelationships between ergonomic, external disruption, and internal disruption in complex laparoscopic procedures. Surgical Endoscopy, 33(11), 3673–3687.

Almerud, S., Alapack, R. J., Fridlund, B., & Ekebergh, M. (2007). Of vigilance and invisibility - being a patient in technologically intense environments. Nursing in Critical Care, 12(3), 151–158.

American College of Surgeons’ Committee on Trauma. (2013). American College of Surgeons’ Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. Journal of Trauma Acute Care Surgery, 74(5), 1363-6.

Anthony, K., Wiencek, C., Bauer, C., Daly, B., & Anthony, M. K. (2010). No Interruptions Please: Impact of a No Interruption Zone on Medication Safety in Intensive Care Units. Critical Care Nurse, 30(3), 21–29.

Asan, O., Holden, R. J., Flynn, K. E., Murkowski, K., & Scanlon, M. C. (2018). Providers’ assessment of a novel interactive health information technology in a pediatric intensive care unit. JAMIA Open, 1(1), 32–41.

Bayramzadeh, S., Joseph, A., San, D., Khoshkenar, A., Taaffe, K., Jafarifiroozabadi, R., & Neyens, D. M. (2018). The Impact of Operating Room Layout on Circulating Nurse’s Work Patterns and Flow Disruptions: A Behavioral Mapping Study. Health Environments Research and Design Journal, 11(3), 124–138.

Bazzi, M., Lundèn, M., Ahlberg, K., Bergbom, I., Hellström, M., Lundgren, S. M., & Fridh, I. (2020). Patients’ lived experiences of waiting for and undergoing endovascular aortic repair in a hybrid operating room: A qualitative study. Journal of Clinical Nursing, 29(5–6), 810–820.

Blikkendaal, M. D., Driessen, S. R. C., Rodrigues, S. P., Rhemrev, J. P. T., Smeets, M. J. G. H., Dankelman, J., van den Dobbelsteen, J. J., & Jansen, F. W. (2017). Surgical flow disturbances in dedicated minimally invasive surgery suites: an observational study to assess its supposed superiority over conventional suites. Surgical Endoscopy, 31(1), 288–298.

Blocker, R. C., Shouhed, D., Gangi, A., Ley, E., Blaha, J., Gewertz, B. L., Wiegmann, D. A., & Catchpole, K. R. (2013). Barriers to Trauma Patient Care Associated with CT Scanning. Journal of the American College of Surgeons, 217(1), 135–141.

Antoniadis, S., Passauer-Baierl, S., Baschnegger, H., & Weigl, M. (2014). Identification and interference of intraoperative distractions and interruptions in operating rooms.

Journal of Surgical Research, 188(1), 21–29.

Boyko, Y., Jennum, P., Nikolic, M., Holst, R., Oerding, H., & Toft, P. (2017). Sleep in intensive care unit: The role of environment. Journal of Critical Care, 37, 99–105.

Asan, O., Flynn, K. E., Azam, L., & Scanlon, M. C. (2017). Nurses’ Perceptions of a Novel Health Information Technology: A Qualitative Study in the Pediatric Intensive Care Unit. International Journal of Human–Computer Interaction, 33(4), 258–264.

Broom, M., Kecskes, Z., Kildea, S., & Gardner, A. (2019). Exploring the Impact of a Dual Occupancy Neonatal Intensive Care Unit on Staff Workflow, Activity, and Their Perceptions. Health Environments Research and Design Journal, 12(2), 44–54.

71

References Campbell, G., Arfanis, K., & Smith, A. F. (2012). Distraction and interruption in anaesthetic practice. British Journal of Anaesthesia, 109(5), 707–715.

Carayon, P., Hundt, A. S., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith, M., & Brennan, P. F. (2006). Work system design for patient safety: The SEIPS model. BMJ Quality & Safety, 15(suppl 1), i50-i58.

Castro, R. A., Angus, D. C., Hong, S. Y., Lee, C., Weissfeld, L. A., Clermont, G., & Rosengart, M. R. (2012). Light and the outcome of the critically ill: an observational cohort study. Critical Care, 16(4), R132.

Catchpole, K., Ley, E., Wiegmann, D., Blaha, J., Shouhed, D., Gangi, A., Blocker, R., Karl, R., Karl, C., Taggart, B., Starnes, B., & Gewertz, B. (2014). A Human Factors Subsystems Approach to Trauma Care. JAMA Surgery, 149(9), 962–968.

Center for Disease Control. (2016). Cost of injuries and violence in the United States.

Retrieved from https://www.cdc.gov/injury/wisqars/overview/cost_of_injury.html Chen, X., Xu, B., Meng, X., Zhang, J., Yu, X., & Zhou, D. (2011). Dual-room 1.5-T intraoperative magnetic resonance imaging suite with a movable magnet: implementation and preliminary experience. Neurosurgical Review, 35(1), 95–110.

Cohen, T. N., Cabrera, J. S., Sisk, O. D., Welsh, K. L., Abernathy, J. H., Reeves, S. T., Wiegmann, D. A., Shappell, S. A., & Boquet, A. J. (2016). Identifying workflow disruptions in the cardiovascular operating room. Anaesthesia, 71(8), 948–954.

Craker, N. C., Myers, R. A., Eid, J., Parikh, P., McCarthy, M. C., Zink, K., & Parikh, P. J. (2017).

Nursing Interruptions in a Trauma Intensive Care Unit. JONA: The Journal of Nursing Administration, 47(4), 205–211.

72

Czaplik, M., Rossaint, R., Kaliciak, J., Follmann, A., Kirfel, S., Scharrer, R., Guski, M., Vorländer, M., Marx, G., & Coburn, M. (2016). Psychoacoustic analysis of noise and the application of earplugs in an ICU. European Journal of Anaesthesiology, 33(1), 14–21.

Drews, F. A., Markewitz, B. A., Stoddard, G. J., & Samore, M. H. (2019). Interruptions and Delivery of Care in the Intensive Care Unit. Human Factors: The Journal of the Human Factors and Ergonomics Society, 61(4), 564–576.

Eliassen, K. M., & Hopstock, L. A. (2011). Sleep promotion in the intensive care unit—A survey of nurses’ interventions. Intensive and Critical Care Nursing, 27(3), 138–142.

Estrup, S., Kjer, C. K. W., Poulsen, L. M., Gøgenur, I., & Mathiesen, O. (2018). Delirium and effect of circadian light in the intensive care unit: a retrospective cohort study. Acta Anaesthesiologica Scandinavica, 62(3), 367–375.

Fan, E. P., Abbott, S. M., Reid, K. J., Zee, P. C., & Maas, M. B. (2017). Abnormal environmental light exposure in the intensive care environment. Journal of Critical Care, 40, 11–14.

Farokhnezhad Afshar, P., Bahramnezhad, F., Asgari, P., & Shiri, M. (2016). Effect of White Noise on Sleep in Patients Admitted to a Coronary Care. Journal of Caring Sciences, 5(2), 103–109.

Frellesen, C., Boettcher, M., Wichmann, J. L., Drieske, M., Kerl, J. M., Lehnert, T., Nau, C., Geiger, E., Wutzler, S., Ackermann, H., Vogl, T. J., & Bauer, R. W. (2015). Evaluation of a dual-room sliding gantry CT concept for workflow optimisation in polytrauma and regular in- and outpatient management. European Journal of Radiology, 84(1), 117–122.

Gharaveis, A., Yekita, H., & Shamloo, G. (2020). The Perceptions of Nurses About the Behavioral Needs for Daylighting and View to the Outside in Inpatient Facilities.

References HERD: Health Environments Research & Design Journal, 13(1), 191–205.

Göras, C., Olin, K., Unbeck, M., Pukk-Härenstam, K., Ehrenberg, A., Tessma, M. K., Nilsson, U., & Ekstedt, M. (2019). Tasks, multitasking and interruptions among the surgical team in an operating room: a prospective observational study. BMJ Open, 9(5), e026410.

Healey, A. N., Primus, C. P., & Koutantji, M. (2007). Quantifying distraction and interruption in urological surgery. Quality and Safety in Health Care, 16(2), 135–139.

Healey, A. N., Sevdalis, N., & Vincent, C. A. (2006). Measuring intra-operative interference from distraction and interruption observedin the operating theatre. Ergonomics, 49(5–6), 589–604.

Heidemann, A. M., Cândido, A. P. L., Kosour, C., Costa, A. R. de O., & Dragosavac, D. (2011).

The influence of noise levels on the perception of stress in heart disease patients.

Revista Brasileira de Terapia Intensiva, 23(1), 62–67.

Hicks, C., & Petrosoniak, A. (2018). The human factor: Optimizing trauma team performance in dynamic clinical environments. Emergency Medicine Clinics, 36(1), 1-17.

Ivatury, R. R., Guilford, K., Malhotra, A. K., Duane, T., Aboutanos, M., & Martin, N. (2008).

Patient safety in trauma: Maximal impact management errors at a level I trauma center. Journal of Trauma and Acute Care Surgery, 64(2), 265-272.

Johansson, L., Bergbom, I., Waye, K. P., Ryherd, E., & Lindahl, B. (2012). The sound environment in an ICU patient room—A content analysis of sound levels and patient experiences. Intensive and Critical Care Nursing, 28(5), 269–279.

Johansson, L., Knutsson, S., Bergbom, I., & Lindahl, B. (2016). Noise in the ICU patient room

– Staff knowledge and clinical improvements. Intensive and Critical Care Nursing, 35, 1–9.

Joseph, A., Bayramzadeh, S., Zamani, Z., & Rostenberg, B. (2017). Safety, performance, and satisfaction outcomes in the operating room: A literature review. Health Environments Research & Design Journal, 11(2), 137-150.

Joseph, A., Khoshkenar, A., Taaffe, K. M., Catchpole, K., Machry, H., & Bayramzadeh, S. (2019). Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room. BMJ Quality & Safety, 28(4), 276–283.

Kinoshita, T., Hayashi, M., Yamakawa, K., Watanabe, A., Yoshimura, J., Hamasaki, T., & Fujimi, S. (2018). Effect of the Hybrid Emergency Room System on Functional Outcome in Patients with Severe Traumatic Brain Injury. World Neurosurgery, 118, e792–e799.

Kippnich, M., Schorscher, N., Kredel, M., Markus, C., Eden, L., Gassenmaier, T., Lock, J., & Wurmb, T. (2020). Dual-room twin-CT scanner in multiple trauma care: first results after implementation in a level one trauma centre. European Journal of Trauma and Emergency Surgery.

Kol, E., Demircan, A., Erdoğan, A., Gencer, Z., & Erengin, H. (2015). The Effectiveness of Measures Aimed at Noise Reduction in an Intensive Care Unit. Workplace Health & Safety, 63(12), 539–545.

Lenski, M., Hofereiter, J., Terpolilli, N., Sandner, T., Zausinger, S., Tonn, J.-C., Kreth, F.-W., & Schichor, C. (2019). Dual-room CT with a sliding gantry for intraoperative imaging: feasibility and workflow analysis of an interdisciplinary concept. International Journal of Computer Assisted Radiology and Surgery, 14(2), 397–407.

Li, S.-Y., Wang, T.-J., Vivienne Wu, S. F., Liang, S.-Y., & Tung, H.-H. (2011). Efficacy of controlling night-time noise and activities to improve patients’ sleep quality in a

73

References surgical intensive care unit. Journal of Clinical Nursing, 20(3–4), 396–407.

Locsin, R. C., & Kongsuwan, W. (2013). Lived experience of patients being cared for in ICUs in Southern Thailand. Nursing in Critical Care, 18(4), 200–211. 5 Luetz, A., Weiss, B., Penzel, T., Fietze, I., Glos, M., Wernecke, K. D., Bluemke, B., Dehn, A. M., Willemeit, T., Finke, A., & Spies, C. (2016). Feasibility of noise reduction by a modification in ICU environment. Physiological Measurement, 37(7), 1041–1055.

McGrath, M. (2008). The challenges of caring in a technological environment: critical care nurses’ experiences. Journal of Clinical Nursing, 17(8), 1096–1104.

Petrosoniak, A., Almeida, R., Pozzobon, L. D., Hicks, C., Fan, M., White, K., ... & Trbovich, P. (2018). Tracking workflow during high-stakes resuscitation: The application of a novel clinician movement tracing tool during in situ trauma simulation. BMJ Simulation and Technology Enhanced Learning, 0, 1-7.

Prates, D. de O., & Silva, A. E. B. de C. (2016). Interruptions of activities experienced by nursing professionals in an intensive care unit. Revista Latino-Americana de Enfermagem, 24.

Meriläinen, M., Kyngäs, H., & Ala-Kokko, T. (2010). 24-Hour intensive care: An observational study of an environment and events. Intensive and Critical Care Nursing, 26(5), 246–253.

Reinke, L., Haveman, M., Horsten, S., Falck, T., van der Heide, E. M., Pastoor, S., van der Hoeven, J. H., Absalom, A. R., & Tulleken, J. E. (2019). The importance of the intensive care unit environment in sleep—A study with healthy participants. Journal of Sleep Research, 29(2), e12959.

Nannapaneni, S., Lee, S. J., Kashiouris, M., Elmer, J. L., Thakur, L. K., Nelson, S. B., Bowron, C. T., Danielson, R. D., Surani, S., & Ramar, K. (2015). Preliminary noise reduction efforts in a medical intensive care unit. Hospital Practice, 43(2), 94–100.

Rogers, F. B., Rittenhouse, K. J., & Gross, B. W. (2015). The golden hour in trauma: Dogma or medical folklore? Injury, 46(4), 525-527.

Neyens, D. M., Bayramzadeh, S., Catchpole, K., Joseph, A., Taaffe, K., Jurewicz, K., Khoshkenar, A., & San, D. (2019). Using a systems approach to evaluate a circulating nurse’s work patterns and workflow disruptions. Applied Ergonomics, 78, 293–300.

Olausson, S., Lindahl, B., & Ekebergh, M. (2013). A phenomenological study of experiences of being cared for in a critical care setting: The meanings of the patient room as a place of care. Intensive and Critical Care Nursing, 29(4), 234–243.

Pennathur, P. R., Thompson, D., Abernathy, J. H., Martinez, E. A., Pronovost, P. J., Kim, G. R., Bauer, L. C., Lubomski, L. H., Marsteller, J. A., & Gurses, A. P. (2013). Technologies in

74

the wild (TiW): human factors implications for patient safety in the cardiovascular operating room. Ergonomics, 56(2), 205–219.

Sarcevic, A. (2009, May). A study of collaborative information behavior in trauma resuscitation. In Collaborative Information Behavior Workshop at Group (pp.

1-4).

Sasangohar, F., Donmez, B., Easty, A., Storey, H., & Trbovich, P. (2014). Interruptions experienced by cardiovascular intensive care unit nurses: An observational study.

Journal of Critical Care, 29(5), 848–853.

Shouhed, D., Blocker, R., Gangi, A., Ley, E., Blaha, J., Margulies, D., Wiegmann, D. A., Starnes, B., Karl, C., Karl, R., Gewertz, B. L., & Catchpole, K. R. (2014). Flow Disruptions During Trauma Care. World Journal of Surgery, 38(2), 314–321.

References Spooner, A. J., Chaboyer, W., & Aitken, L. M. (2019). Interruptions During Senior Nurse Handover in the Intensive Care Unit. Journal of Nursing Care Quality, 34(1), E15–E21.

Stahl, J. E., Sandberg, W. S., Daily, B., Wikulnd, R., Egan, M. T., Goldman, J. M., Isaacson, K. B., Gazelle, S., & Rattner, D. W. (2006). Reorganizing patient care and workflow in the operating room: a cost-effectiveness study. Surgery, 139(6), 717–728.

Stayt, L. C., Seers, K., & Tutton, E. (2015). Patients’ experiences of technology and care in adult intensive care. Journal of Advanced Nursing, 71(9), 2051–2061.

Wulffeld, S., Rasmussen, L. S., Højlund Bech, B., & Steinmetz, J. (2017). The effect of CT scanners in the trauma room - an observational study. Acta Anaesthesiologica Scandinavica, 61(7), 832–840. Xie, H., & Kang, J. (2012). The acoustic environment of intensive care wards based on long period nocturnal measurements. Noise and Health, 14(60), 230–236.

Yoong, W., Khin, A., Ramlal, N., Loabile, B., & Forman, S. (2015). Interruptions and distractions in the gynaecological operating theatre: irritating or dangerous?

Ergonomics, 58(8), 1314–1319.

Tegnestedt, C., Günther, A., Reichard, A., Bjurström, R., Alvarsson, J., Martling, C.-R., & Sackey, P. (2013). Levels and sources of sound in the intensive care unit - an observational study of three room types. Acta Anaesthesiologica Scandinavica, 57(8), 1041–1050.

Terzi, B., Azizoğlu, F., Polat, Ş., Kaya, N., & İşsever, H. (2019). The effects of noise levels on nurses in intensive care units. Nursing in Critical Care, 24(5), 299–305.

Tunlind, A., Granström, J., & Engström, Å. (2015). Nursing care in a high-technological environment: Experiences of critical care nurses. Intensive and Critical Care Nursing, 31(2), 116–123. Vioque, S. M., Kim, P. K., McMaster, J., Gallagher, J., Allen, S. R., Holena, D. N., ... & Pascual, J. L. (2014). Classifying errors in preventable and potentially preventable trauma deaths: A 9-year review using the Joint Commission’s standardized methodology. The American Journal of Surgery, 208(2), 187-194.

Weigl, M., Antoniadis, S., Chiapponi, C., Bruns, C., & Sevdalis, N. (2015). The impact of intraoperative interruptions on surgeons’ perceived workload: an observational study in elective general and orthopedic surgery. Surgical Endoscopy, 29(1), 145–153.

75