Toward a Model of Safety and Care for Trauma Room Design | Volume 2 by HealthcareDesignKentState

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 Editorial Assistants: Leong Yin Tanya Chiu, Hamid Estejab Graphic Designer: Parsa Aghaei

Table of Contents

Overview 4

Phase 1 overview 30

RESEARCH INTEGRATED DESIGN PROCESS

Next Steps 96

Advisory Committee

100

39 Healthcare design studio 40 Journey maps 60 Design thinking sessions 32 Literature review

68 Design variations

34 Case Studies

82 Mock-up construction

36 Focus group

88 Scenario-based simulations

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.

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

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

......

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.

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

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

Sahar Ahmadpour

Parsa Aghaei

Graduate Research Assistant Healthcare Design Program

Hossein Mirzajani

Leong Yin Tanya Chiu

Graduate Research Assistant Healthcare Design Program

Hamid Estejab

Md Mazharul Islam

Graduate Research Assistant Healthcare Design Program

Zhengyong Ren

Kayla O’Donnell

S T U D E N T S Ph.D. Student, Research Assistant Computer Science Program

Madeline Sterling Nursing Honors Student

Nursing Honors 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).

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.

Project Timeline

Phase 4 Implementation

Phase 1 Problem Analysis

2023

2021

2019

2022

Phase 2 & 3 Design +Development

Phase 5 Evaluation

Project Foci

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). 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:

• 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.

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

Framework This study uses the Systems 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.

SEIPS

Systems 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

ﬁc

C a re

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

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

Five Phases

Phase

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

Problem Analysis

Phases

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

Phase

• High-Fidelity Physical Mock-Up • Systematic Observations

Implementation

Phase

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

Design+Development Evaluation

Phases Two and Three Accomplishments Design & Development Phases The design and development phases included integration of a design studio course into the research project. The studio students developed design variations for Level I trauma rooms. Since design is an iterative process, we conducted evaluations to test the design variations after the studio concluded. Staff Journey Maps – Interviews with trauma team members were conducted to understand their roles and responsibilities during a trauma activation. Trauma Design Studio Course – The Master of Healthcare Design program at Kent State University dedicated a Healthcare Design studio to designing Level I trauma rooms. Design Thinking Sessions – Two interactive sessions were conducted to brainstorm design solutions with trauma team members. Low-Fidelity Mock-Up Construction – A physical mock-up was built as part of the Healthcare Design studio to provide an opportunity for end-users to engage and evaluate the design ideas. Scenario-Based Simulations – Three trauma simulations were conducted with clinicians to evaluate various design elements and strategies by enactment of relevant tasks using the full-scale physical mock-up.

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 20

Site Introduction

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

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

Flow of Patient Care: Entering from Emergency Department Main Entrance

Patient transferred to stretcher

Primary survey

Secondary survey

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

Patient receives imaging in trauma bay or CT in radiology suite

Procedures

Start

End

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

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

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.

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

Methodology & Research-Integrated Design Approach

Journey Maps

Design Thinking

Design Variations

Understand the roles and responsibilities of trauma team members during a trauma activation through interviews

Brainstorm design solutions with trauma team members for better trauma room design through interactive sessions

Develop three design variations of Level I trauma rooms

Mock-Up Construction

Simulations

Build a low-fidelity, full scale physical mock-up

Evaluate various design elements or strategies by simulating clinical scenarios or enactment of relevant tasks with trauma team members through a full-scale physical mock-up

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?

PHASE 1 (PROBLEM ANALYSIS) OVERVIEW

Phase 1 Overview The phase one of the project (problem analysis) is already completed and reported in detail a separate booklet. The following pages will briefly review the results and processes of what was done in phase one. Literature Review A comprehensive literature review based on the four identified subjects of workflow, interruptions and disruptions, technology, and sensory factors was done to find out the exisiting empirical knowledge on the design of trauma rooms. Case Studies Trauma rooms around the U.S. utilize different layouts with unique floor plans. This exercise aimed to discover the strengths and weaknesses of different level I trauma room designs in different hospitals throughout the country. Focus group 21 focus group sessions with 69 clinicians who worked in the setting of level I trauma rooms were performed to find out about their needs, shortcomings, and attitudes regarding the physical environment of trauma rooms.

Literature Review: Overview Topics: Workflow

Disruptions & Interruptions

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.

Technology

Sensory Factors

Workflow

Interruptions & Disruptions

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.

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 (Bayramzadeh et al., 2021).

Technology

Sensory Factors

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 (Bayramzadeh & Aghaei, 2021).

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 (Bayramzadeh et al., 2021).

Case Studies: Overview 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.

Case Studies: Floor Plans Location: Georgia Layout: Enclosed Room Room size: 280 sq.ft

Location: New York Layout: Semi-Open Room Room size: 328 sq.ft

Location: Ohio Layout: Enclosed Room Room size: 510 sq.ft

Location: Ohio Layout: Enclosed Room Room size: 741 sq.ft

Location: Texas Layout: Enclosed Room Room size: 415 sq.ft

Focus Groups: Overview 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.

Sessions

Participants

Roles

Malfunctions

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

Layout

Documenting nurse needs the computer facing the patient.

Underutilization

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

Learning Curve

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

Challenges

Workflow

Technology

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.

Challenges

Crowding

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

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.

Temperature fluctuations

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.

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.

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.

Sensory Factors

Interruptions & Disruption

Challenges

RESEARCH-INTEGRATED DESIGN PROCESS

Healthcare Design Studio The Master of Healthcare Design program at Kent State University dedicated a Healthcare Design studio to designing the trauma room. The studio aimed to develop design variations with innovative solutions for issues related to workflow, disruptions and interruptions, technology integration, and sensory stimuli in trauma rooms. The studio project was based on the research and tools developed by the PI and the research team. The studio integrated research into the design process to help students base their design decisions on credible evidence. It further involved a cross-disciplinary team of healthcare professionals (e.g., surgeons, nurses, EM physicians) and architects who provided

feedback during the mid and final design reviews. The course comprised four milestones: research (journey maps, design thinking sessions), individual design projects, group design projects, and mockup construction. The journey maps and design thinking sessions involved end-users and served as a design exercise to understand the nature of the trauma care process and the users’ needs. Then students were tasked to design three variations for a safer and more efficient trauma room based on three eras – the current state, 25 years from now, and 50 years from now.

Individual Design Projects

Mock-up Construction

Three variations

Research

Group Projects

Interviews, design thinking sessions, design guide development

Three variations

RESEARCH-INTEGRATED DESIGN PROCESS

JOURNEY MAPS

Journey Maps A journey map helps visualize the process that a person goes through to accomplish a goal. At the beginning of the Healthcare design studio, we utilized individual interviews with clinicians to visually showcase each trauma team member’s journey map. The participating clinicians included trauma team members (listed below) from various Level I trauma facilities in the United States to understand their tasks, interactions with other team members, equipment touchpoints, and challenges as they collectively follow the steps of a trauma procedure. We divided the trauma procedure into six phases of Pre-Arrival, Primary Survey, Secondary Survey, Imaging, Patient Discharge, and Room Restocks. Although the trauma procedure is not necessarily a linear process, to simplify the journey maps, we depicted a linear process with six phases. Trauma team roles interviewed: Emergency Medicine (EM) technician Pharmacist Advanced practice provider Respiratory therapist General surgery (GS) resident senior GS resident junior Primary nurse EM resident EM attending

Role:

Touchpoints

Actions

EM Tech Pre-Arrival

Primary Survey

Making sure bed, Monitor, monitor cords and equipment in working condition and are in the room cleaned

Held with transfer of patient to bed. Looking for any in juries on arm. Cut clothes off and perform a manual blood pressure. Call out the reading so the primary nurse and trauma team hears. Place heart monitor on patient. Stand back and listen for when staff members need supplies and waiting for blood so I can label and send to lab

Making sure the bed is zeroed

High

• GS Resident Senior • EM Resident

Moderate

Equipment Challenges 42

Low

• GS Resident Senior • Respiratory Therapist

• Trauma Surgeon

• EM Attending

• GS Resident Junior

• EM Resident

• X-Ray Tech

• GS Resident Junior

• Charge Nurse

• Primary Nurse

• EM Attending

• Charge Nurse

• X-Ray Tech

• EM Tech

• Pharmacist

• APP

• EM Tech High

Moderate

• Respiratory Therapist • Trauma Surgeon

• Primary Nurse

• Carts

High

Low

Secondary Survey 1- If no one sees an injury that I have seen, I speak up. Other than that I do not assess patients

High • Primary Nurse • EM Tech

• Pharmacist Moderate

Low

Moderate

High

• Light Boom

• WOW

• Light Boom

• IV Poles

• Control Panel

• Ultrasound Machine

• Control Panel

• WOW

• Carts

• IV Poles

1- Making sure all equipment is in the room, cleaned and in working order 2- Have a better understanding of what is coming in 3. Having to many people in the room, making it hard to do our jobs

Low • Ultrasound Machine

Moderate

• Trauma Surgeon

• EM Resident

• GS Resident Junior

• Respiratory Therapist

• Charge Nurse

• X-Ray Tech

• APP

• EM Attending

• Pharmacist

High

Moderate • Light Boom • Control Panel • Carts • IV Poles

Same as pre-arrival phase

Low

• GS Resident Senior

Same as pre-arrival phase

• WOW

Low • Ultrasound Machine

Imaging

Patient Discharge

1- Wheeling patients to exams while making sure patient handrails are up and locked and making sure monitor comes with patient and if in working condition.

Room Restocks

None

1- Making sure we have adequate supplies 2- Making sure bed, monitor and monitor cords come back from or or floor

2- Transferring patient from cart to CT bed safely

3- Keeping up any trash on the floor for housekeeping can clean

3- Helping transfer patient back to cart. and wheeling pt back to room assigned if any High • GS Resident Senior • Primary Nurse • EM Tech

Low

High

Moderate

• Trauma Surgeon

• GS Resident Junior

• Primary Nurse

• EM Resident

• Charge Nurse

• Respiratory Therapist

• APP

• X-Ray Tech

• AS Pharmacist

Moderate

• Charge Nurse • EM Tech • EM Attending

• EM Attending High • Carts

None

Moderate • IV Poles

Low

High

• Trauma Surgeon

• Respiratory Therapist

• GS Resident Junior

• APP

• GS Resident Senior

• Pharmacist

Moderate

• Light Boom

• Control Panel

• Control Panel • WOW

• WOW

• Carts

None

Low

• IV Poles

High • Primary Nurse

Low

• EM Resident

• Trauma Surgeon

• Charge Nurse

• GS Resident Junior

• APP

• GS Resident Senior

• Pharmacist

• EM Tech

• X-Ray Tech

Low

Moderate

• EM Attending

Therapist • X-Ray Tech

• Respiratory High

• Ultrasound Machine

Moderate • Light Boom

• IV Poles

• Control Panel

• WOW

Low • Ultrasound Machine

• Carts

None

Role:

Pharmacist Pre-Arrival

Primary Survey Obtain any relevant information from pre-hospital EMS regarding medication history or mediations administered prior to arrival

Prepare anticipated medication

High

Moderate

• Primary Nurse

• GS Resident Junior

• EM Attending

• GS Resident Senior

Equipment

• Trauma Surgeon

• ED Paramedic

Ongoing support for medications

Prepare medications for emergent conditions, such as intubation, TBI/herniation, ACLS, etc.

Identify and facilitate appropriate treatment

Touchpoints

Actions

Review report for incoming patient

• EM Resident

Secondary Survey

High

Low • Respiratory Therapist • Charge Nurse • EM Tech

Moderate

Low

High

• Trauma Surgeon

• GS Resident Junior

• Respiratory Therapist

• Trauma Surgeon

• GS Resident Senior

• Pre-hospital EMS

• EM Tech

• EM Resident

• Primary Nurse

• EM Attending

High

Moderate

Low

High

Moderate

Low

High

• Carts

• Blood Defuser

• Carts

• WOW

• Carts

• Pyxis

• WOW

• Ventilator

• IV Poles

• Cardiac Monitor

• IV Poles

Challenges

Low • GS Resident Senior

Moderate

Low

• EM Attending

• IV Poles

Moderate • GS Resident Junior

• Pyxis

Lack of access to computers in trauma bay - there is only one functional computer (aside from the trauma charting RN) and this is used by GS resident to document and place orders. One of the key roles of pharmacist is to rapidly review a trauma patient’s medical record for key medical history and medication use which may acutely impact trauma management.

When preparing medications for administration and programming IV pumps, it can be challenging to access the IV pole (right side of bed) as this is where the monitor is and frequently RT sets up the ventilator on this side. Depending on the number and types of medications which need to be prepared, there is limited workspace to reconstitute medication, prime tubing, etc by the Pyxis. This can make it very challenging to quickly and safety prepare medications.

• WOW

• Pyxis

Access to IV pole can be challenging. ED pharmacist will often help facilitate vitals assessment, recycling blood pressure and access to cardiac monitor can be challenging as well. Occasionally the ED pharmacist may need to investigate medications given pre-hospital (e.g. reversal agents) or patient’s home medications/medical history which would impact further treatment and there is rarely a computer available. This is done on a patient specific basis (a patient with unclear neurologic status, opioid use/OARRS data, hypotensive patients without compensatory tachycardia, etc.)

Imaging

Patient Discharge

Facilitate medication therapy.

Room Restocks

Ensure that adequate medications for sedation, analgesia, antimicrobial prophylaxis, anticoagulation/antiplatelet reversal, etc have all been received by the patient.

None

Sometimes facilitate medications being delivered to the OR. Accompany hemodynamically unstable patients to the OR.

High

Moderate

• EM Resident

• Trauma Surgeon

• Primary Nurse

• GS Resident Junior

• EM Attending

• GS Resident Senior

Low

High

Moderate

• X-Ray Tech

• GS Resident Senior

• Anesthesiologist

Low • Trauma Surgeon

None

• GS Resident Junior

• Primary Nurse

• EM Resident • Respiratory Therapist • EM Attending

High • IV Poles

Moderate

Low

• WOW

High • IV Poles

Moderate

Low

• Pyxis

None

• Pyxis

Access to some medications is challenging when patient is in CT but typically we can leave CT and obtain the needed medications quickly. Monitoring a hemodynamically labile patient in CT using the travel cardiac monitor is challenging and difficult to see from the reading room.

Handoff to the OR from the ED team is difficult because it is unclear who needs to be given handoff information.

Not specific to this phase of trauma, but when we have multiple traumas, it is common for rooms to be inadequately stocked for the next trauma. Roles for restocking are not always clear so it is common for IV pumps, supplies in the cabinet (syringes, flushes), etc to be low or out of stock which causes delays in care for the next trauma patient.

Role:

Advanced Practice Provider Primary Survey Perform ABCs

Perform secondary survey

Prepare equipment as needed (i.e. chest tube)

Access patient in computer and place orders

Place orders in chart

Log into wall computer to prepare orders

Review chart if applicable

Review chart contact other specialties

High

• GS Resident Junior • GS Resident Senior

Moderate

• APP • EM Tech

• Respiratory Therapist • X-Ray Tech

High

Low • Trauma Surgeon • Charge Nurse

• GS Resident Junior

• APP

• GS Resident Senior

• Pharmacist

• EM Resident

• Primary Nurse

Equipment

• EM Resident

High

Challenges

• Wall Computer

Secondary Survey

Receive any patient info

Touchpoints

Actions

Pre-Arrival

Moderate

Low • Light Boom

• Blood Fridge • WOW

• Control Panel • Blood Defuser • Ultrasound Machine • Carts • Pyxis • X-Ray • IV Poles • Ventilator Machine

Lack of info for incoming patient, lack of time to prepare prior to patient arrival.

High

• EM Attending

Low • Trauma Surgeon

• GS Resident Junior

• X-Ray Tech

• EM Tech

• Charge Nurse

• GS Resident Senior

• Pharmacist

• X-Ray Tech

High

Moderate

• EM Attending

• EM Resident

• Respiratory Therapist • Primary Nurse

Low • Trauma • Charge Nurse Surgeon

• EM Tech

• APP

Moderate

• X-Ray • Wall Computer Machine

Moderate • Respiratory Therapist

Low

High

• Light Boom • Blood Fridge • WOW • Control Panel

• Blood Defuser

• Carts

• Pyxis

• IV Poles

• Ventilator

• Ultrasound Machine

Disorganization, too many voices (side conversation)

• X-Ray Machine • Wall Computer

Moderate

Low • Light Boom • Pyxis • Control Panel • Carts • IV Poles

• Ventilator • WOW • Ultrasound Machine

• Blood Fridge • Blood Defuser

Too much noise Lack of exam consistency (disorganization)

Imaging

Patient Discharge

Room Restocks

Package patient (transport monitor, vent if applicable)

Communicate disposition with ED staff

Take patient to CT Move onto CT table

Communicate with specialties (ortho, neurosurgery)

High • GS Resident Junior • GS Resident Senior • EM Resident

Moderate

• Primary Nurse • Respiratory Therapist • X-Ray Tech • EM Tech • Pharmacist • EM Attending • CT Tech

Low • Trauma Surgeon • Charge Nurse

High • IV Poles

Moderate • Ventilator

Low • Light Boom • WOW • Control Panel

• Ultrasound Machine

• Pyxis

• X-Ray Machine

Waiting for CT to be available

• Blood Defuser

Low

• EM Resident

• Trauma Surgeon

• Respiratory Therapist

• APP

• GS Resident Junior

• Charge Nurse

• GS Resident Senior

• EM Tech

• Primary Nurse

• X-Ray Tech

• EM Attending

• Pharmacist

High • Blood Fridge

Moderate

High

• APP • Carts

None

Moderate

Low • Light Boom

• Blood Fridge

• WOW

None

• Control Panel • Blood Defuser • Ultrasound Machine • Carts • Pyxis • X-Ray • IV Poles • Ventilator Machine

Lack of space in-house for patients to be moved

None

Role:

Respiratory Therapist Pre-Arrival Actions

Check for proper airway equipment, fullO2 tank, and proper PPE

Secondary Survey

Application of oxygen

Check if escalation in respiratory care is needed

Place patient on the monitor Assess the airway

High • GS Resident Junior • GS Resident Senior • EM Resident

Moderate • Trauma Surgeon • Pharmacist

• Respiratory Therapist

Low

High

Moderate

• Charge Nurse

• GS Resident Junior

• Trauma Surgeon

• APP

• GS Resident Senior

• EM Resident

• EM Tech

• Respiratory Therapist

• EM Attending

• Primary Nurse

Low

High

Moderate

Low

• Charge Nurse

• Trauma Surgeon

• GS Resident Junior

• APP

• Respiratory Therapist

• GS Resident Senior

• Charge Nurse

• EM Tech

• Primary Nurse

• EM Resident • EM Attending

• Primary Nurse

Equipment

Touchpoints

Primary Survey

High

Challenges

• Ventilator

Moderate

Low • Carts • WOW

Whether or not equipment that was used for prior traumas has been cleaned and/or replaced.

High • Ventilator

Moderate

Low • Carts

High

Moderate

• Ventilator

• WOW

Getting a proper view of the patient while everyone else is trying to do their own thing.

Low • Carts

Availability of proper functioning equipment.

Imaging

Patient Discharge

Place patient on proper transport equipment

High

Room Restocks

Patient stable from a respiratory stand point

Moderate

Low

• Respiratory Therapist

• Trauma Surgeon

• Primary Nurse

• GS Resident Junior

• Charge Nurse

• GS Resident Senior

High

Moderate

• Trauma Surgeon

• GS Resident Junior

• Respiratory Therapist

• GS Resident Senior

• Primary Nurse

• EM Resident

Replace items that were used

Low • Charge Nurse

High • Respiratory Therapist

Moderate

Low

• Charge Nurse

• Primary Nurse

• EM Resident

High • Ventilator

Moderate • Carts

Low • WOW

High • Ventilator

Moderate • Carts

High

Low • WOW

• Ventilator

Moderate • Carts

Low • IV Poles

• IV Poles

Equipment availability.

None

Role:

GS Resident Senior

Touchpoints

Actions

Pre-Arrival Discuss with ED attending/resident to obtain any information we know. Don PPE Confirm the trauma attending on call. Check in with nurse so they know senior is involved. Make sure junior surgery residents are present and prepared High

• GS Resident Junior

Challenges

Equipment

• EM Attending

Primary Survey

Moderate

Secondary Survey

Observe ED resident and junior from foot of the bed.

Observation

Helping with exposure and exam

Assist with exam when needed Prepare to call attending if level 2

High

Low

Moderate

Low

High

Moderate

Low

• EM Resident

• Trauma Surgeon

• GS Resident Junior

• Trauma Surgeon

• Charge Nurse

• Trauma Surgeon

• Primary Nurse

• Respiratory Therapist

• EM Resident

• Respiratory Therapist

• EM Tech

• GS Resident Junior

• X-Ray Tech

• EM Attending

• Primary Nurse

• Pharmacist

• EM Resident

• Respiratory • EM Tech Therapist • Pharmacist • Charge Nurse

• Advanced Practice Provider • X-Ray Tech • Pharmacist

• Charge Nurse

• APP

• EM Tech

• EM Attending

• APP

• X-Ray Tech

None

Not enough advance notification or inaccurate timing of trauma arrival.

The junior residents will say there is crowding around the patient between nurses on arms and techs getting vitals, etc., not a lot of space. also, noise level and hearing primary survey report

High

Moderate

Low

• Control Panel

Make sure there is a computer available for the intern/APP from trauma surgery to use (usually there is, but sometimes a nurse uses the wall computer)

Imaging

Patient Discharge

Call and update trauma attending, determine necessary images. View images

Room Restocks

Determine the level of care needed.

None

Report back to ED. Will help with orders for admission, bed requests, etc.

Assist moving patient Determine if pt needs to stay in trauma bay or can go to another room High

Moderate

High

Low

• Trauma Surgeon

• EM Resident

• Primary Nurse

• EM Tech

• Trauma Surgeon

• GS Resident Junior

• Respiratory Therapist

• Charge Nurse

• Pharmacist

• GS Resident Junior

• X-Ray Tech

• EM Resident

• APP

• EM Attending High

Moderate

• IV Poles

• Ventilator

Moderate

Low • Respiratory Therapist • Primary Nurse • Charge

NurseEM Tech

None

• X-Ray Tech • Pharmacist

• EM Attending Low • Light Boom • Control Panel • Carts • Blood Fridge

• Blood Defuser

• Ultrasound Machine

• Pyxis

• X-Ray Machine

• WOW

Sometimes having enough people to move patients

None

Role:

GS Resident Junior Pre-Arrival

Primary Survey ABC

IV access

Actions

Interventions

Secondary Survey

High

• EM Resident

• Charge Nurse

• Trauma Surgeon

• GS Resident Junior

• Respiratory Therapist

• APP

• GS Resident Senior

• Primary Nurse

Challenges

Equipment

Touchpoints

Low

• Trauma Surgeon

Moderate

Low

High

Moderate

Low

• GS Resident Junior

• EM Resident

• Trauma Surgeon

• EM Tech

• GS Resident Senior

• Respiratory Therapist

• GS Resident Junior

• EM Attending

• Pharmacist

• GS Resident Senior

• Pharmacist

• APP

None

High

Moderate

Low

High

Moderate

• IV Poles

• Blood Defuser

• Light Boom

• IV Poles

• Control Panel

• Blood Fridge

• Pyxis

• Control Panel

• Blood Fridge

• Ventilator

• Carts

• Blood Defuser

• Carts

• WOW

Noise

Low

• Light Boom

Crowd

Imaging Checking the circulations

Patient Discharge

Room Restocks

Escort patient stretcher to the floors

High

None

Moderate

• Trauma Surgeon

• GS Resident Junior

• EM Resident

• GS Resident Senior

None

Low • Trauma Surgeon • GS Resident Junior

• Respiratory Therapist • Primary Nurse

None

High • Blood Fridge

High

• GS Resident Senior Moderate

Low

Moderate

• EM Resident

• APP

• Respiratory Therapist

• X-Ray Tech

• Primary Nurse

• Pharmacist

Low

• EM Attending

• Charge Nurse

None

• Blood Defuser • Ventilator • WOW

Door way

None

Role:

Primary Nurse Pre-Arrival

Primary Survey

Touchpoints

Actions

Ensure trauma bay including is ready for patient arrival.

Documentation

Begin documentation

Make apppropriate calls to OR and Bloodbank Accompany the patient to radiology for imaging

High

Moderate

High

Low

Moderate

• Blood Fridge

• Light Boom

• Trauma Surgeon

• Primary Nurse

• IV Poles

• Pyxis

• Control Panel

• APP

• Blood Defuser

• Ventilator

• GS Resident Senior

• WOW

• Ultrasound Machine

Challenges

Equipment

• Carts

Secondary Survey

• EM Resident • Respiratory Therapist

• X-Ray Machine High • Carts

Moderate

Low

• Control Panel

• Light Boom

• Ventilator

• IV Poles

• Blood Fridge

• WOW

• Ultrasound Machine

• Blood Defuser • X-Ray Machine • Pyxis

Crowd control

• EM Attending • Pharmacist

• WOW

High

Moderate

• GS Resident Senior • EM Resident

• Charge Nurse

• Respiratory Therapist

• EM Tech

• Primary Nurse

• X-Ray Tech

Moderate

High • Blood Fridge

Low

• GS Resident Junior

Low

• EM Attending • Pharmacist

• Charge Nurse

• APP

• EM Tech Low

• Trauma Surgeon

• X-Ray Tech High

Moderate

Low

• Carts

• Ventilator

• Light Boom

• IV Poles

• WOW

• Carts

• IV Poles

• Ultrasound Machine

• Control Panel

• Blood Defuser

• Ultrasound Machine

• Blood Fridge • Control Panel

• Blood Defuser • Pyxis

• X-Ray Machine

Not being able to hear the primary assessment findings due to noise levels during resuscitation.

• Pyxis • Ventilator

• X-Ray Machine

Keeping up on documentation

• Light Boom

Imaging

Patient Discharge

Accompany the patient to radiology

High

Room Restocks

Call report to nurse

Order supplies from central distribution and restock trauma bay

Moderate

High

Moderate

Low • Charge Nurse

• GS Resident Junior

• Respiratory Therapist

• Trauma Surgeon

• APP

• Pharmacist

• Primary Nurse

• Charge Nurse

• GS Resident Senior

• EM Attending

• GS Resident Senior

• Trauma Surgeon

• APP

• Respiratory Therapist

• GS Resident Junior

• EM Attending

• Primary Nurse

• EM Resident

• EM Tech

Low

• EM Resident

• X-Ray Tech • Pharmacist

High

Moderate

• Primary Nurse

• Trauma Surgeon

• EM Resident • EM Attending • Respiratory • GS Resident Therapist • Pharmacist Junior • APP • GS Resident • X-Ray Tech Senior

• Charge Nurse • EM Tech

• X-Ray Tech High

Moderate

Low

• Carts

• Blood Defuser

• Light Boom

• IV Poles

• Ventilator

• Control Panel

• WOW

• Blood Fridge

• Ultrasound Machine • X-Ray Machine

High

Moderate

High

Moderate

Low

• Carts

• Light Boom

• Pyxis

• Carts

• Pyxis

• IV Poles

• Control Panel

• Ventilator

• IV Poles

• Ventilator

• WOW

• Blood Fridge

• Ultrasound Machine

• WOW

• Blood Defuser

• X-Ray Machine

• Ultrasound

• Pyxis

Transport monitor - hard to monitor vitals from radiology viewing area.

Low

Bed availability

Machine • X-Ray Machine • Light Boom

• Control Panel • Blood Fridge • Blood Defuser

None

Role:

EM Resident Pre-Arrival

Primary Survey

Challenges

Equipment

Touchpoints

Actions

Don PPE

Secondary Survey

EM is in charge of A and B as well as calling out GCS for D

Head/neck

Get report from medic

High

Moderate

• EM Attending

• Trauma Surgeon

• GS Resident Senior

• Respiratory Therapist

• Primary Nurse

• APP

• Charge Nurse

• EM Tech

• Pharmacist High • Carts

Moderate

High

Low

• GS Resident Junior

• X-Ray Tech Low

Moderate

• GS Resident Junior

• Primary Nurse

• GS Resident Senior

• Charge Nurse

• Respiratory Therapist High

• EM Attending

Low

High

Moderate

• APP

• GS Resident Junior

• Trauma Surgeon

• APP

• EM Tech

• GS Resident Senior

• Primary Nurse

• EM Tech

• X-Ray Tech

• Respiratory Therapist • Charge Nurse

• Pharmacist

Low

• X-Ray Tech • EM Attending • Pharmacist

Moderate

Low

• Control Panel

• Light Boom

• Ventilator

• IV Poles

• Blood Fridge

• WOW

• Ultrasound Machine

• Blood Defuser • X-Ray Machine

• IV Poles

• Pyxis

• Blood Fridge

Accurate reports

• Control Panel

• Trauma Surgeon

• Light Boom • Carts

• Blood Defuser

High • WOW

• Pyxis

• Ultrasound Machine

• Ventilator

• X-Ray Machine

None as long as surgery is at beside. Otherwise, I need to check pulses which slows down the survey significantly

Moderate • Light Boom

Low • Control Panel

• Blood Defuser

• Ultrasound Machine

• Carts

• Pyxis

• IV Poles

• Ventilator

• X-Ray Machine

• Blood Fridge • WOW

None. Sometime the C collar requires more hands than we have available but GS is generally helpful

Imaging

Patient Discharge

Follow patient to CT

Room Restocks

Put in bed request after receiving dispo from surgery

None

Watch CT brain at minimum Help move patient

High

Moderate • Trauma Surgeon • GS Resident Junior • GS Resident Senior

High

• APP

• EM Attending

• Respiratory Therapist

• X-Ray Tech

• Pharmacist

• Primary Nurse

• X-Ray Tech

Low • Light Boom

• Pyxis

• Control Panel • Ventilator • IV Poles • Blood Fridge

• Ultrasound Machine

As long as we have enough hands, none

High Moderate

• Charge Nurse

• EM Tech

• GS Resident Junior

Low • GS Resident Senior

• APP

Moderate

• Trauma Surgeon

• Respiratory Therapist

• Charge Nurse

• Carts

High

Low

• EM Attending

High

Moderate

• EM Tech • Pharmacist

• Trauma Surgeon

• Respiratory Therapist

• GS Resident Junior

• Primary Nurse

• GS Resident Senior

• APP

High Moderate

Low

• WOW

• Light Boom

• Blood Fridge

• X-Ray Machine

• Control Panel

• Blood Defuser

• IV Poles

• Blood Defuser • Ultrasound Machine • Pyxis • X-Ray • Ventilator Machine

• Carts

Low

• WOW

Sometimes dispos can take awhile otherwise usually painless

• Charge Nurse

• EM Tech • X-Ray Tech • EM Attending • Pharmacist

Low • Light Boom

• Blood Fridge

• Control Panel

• Blood Defuser • Ultrasound Machine • Pyxis • X-Ray • Ventilator Machine

• Carts • IV Poles

• WOW

None

Role:

EM Attending Pre-Arrival

Primary Survey Airway

None

Challenges

Equipment

Touchpoints

Actions

Go to room

Secondary Survey

High

Moderate

• Trauma Surgeon • GS Resident Junior • GS Resident Senior • EM Resident

• Respiratory Therapist • Primary Nurse • Pharmacist

High

Low

Moderate

Low

• Charge Nurse

• Trauma Surgeon

• EM Tech

• GS Resident Junior

• X-Ray Tech

• GS Resident Senior

• Respiratory Therapist • Charge Nurse • Primary Nurse • EM Tech • X-Ray Tech

• EM Resident

• Pharmacist

• EM Attending

High • Trauma Surgeon

Moderate

• EM Resident

• GS Resident Junior • EM Attending • GS Resident Senior

• Respiratory Therapist

• Pharmacist

• Charge Nurse • EM Tech

• EM Attending

High

Moderate • Pyxis

• X-Ray Tech

High

Low

Moderate

• Carts

• Light Boom

• WOW

• Carts

• Ventilator

• Control Panel • Blood Defuser

• X-Ray Machine

• Ultrasound Machine • Control Panel • WOW

• Ultrasound Machine

• IV Poles

• X-Ray Machine

• IV Poles

• Blood Fridge

• Ventilator

• Blood Fridge

Equipment being where it is supposed to be and functional

None

Low

• Primary Nurse

• Light Boom

• Pyxis • Blood Defuser

Low

High

Moderate

Low

• Ventilator

• WOW

• Light Boom

• Blood Fridge

• Ultrasound Machine

• X-Ray Machine

• Control Panel

• Blood Defuser

• Carts

• Pyxis

• IV Poles

None

Imaging

Patient Discharge

None

High

Moderate

• Trauma Surgeon • GS Resident Junior • GS Resident Senior • EM Resident

• Respiratory Therapist • Primary Nurse • Pharmacist

None

Moderate

High

Low • EM Tech

• GS Resident Junior

• Trauma Surgeon

• Charge Nurse

• X-Ray Tech

• EM Resident • EM Attending

• GS Resident Senior

• Pharmacist

• Charge Nurse

• Respiratory Therapist

• EM Tech

• Primary Nurse High • Ventilator • Ultrasound Machine

Moderate • Light Boom • Control Panel • Carts

None

Room Restocks

Low

• X-Ray Tech Low

• IV Poles

• Pyxis

• EM Tech

• Light Boom

• Blood Fridge

• WOW

• Blood Fridge

• WOW

• X-Ray Tech

• Control Panel

• Blood Defuser

• X-Ray Machine

• Charge Nurse

• Carts

• Pyxis

• Ultrasound Machine

• IV Poles

• Ventilator

• Blood Defuser

None

• APP

Moderate

High

Low

None

• X-Ray Machine

None

RESEARCH-INTEGRATED DESIGN PROCESS

DESIGN THINKING

Design Thinking Design thinking is an innovative approach that helps stakeholders to create products and practices that are more humane, efficient, and equitable. It is all about human-centered design and creative mindset (Ku & Lupton, 2020). In human-centered design, we ask stakeholders how new approaches to a problem can enhance end users’ wellbeings while creative mindset is the process of generating ideas and making them concrete.

We held two virtual design thinking sessions with trauma team members on Miro, an interactive online platform. The goal was to engage trauma team members in the design process through a set of interactive activities and to brainstorm design strategies for trauma room design. By the end of the two sessions, we had a clearer understanding of the needs of trauma team members and the strengths and weaknesses of different design ideas.

Design Thinking For the two design thinking sessions, we designed two activities for trauma team members to brainstorm ideas and discuss virtually. We adopted a “How Might We” method to phrase the questions to generate more ideas.

Design Thinking Session 1: Six Hats of Thinking In the first session, we utilized six hats of thinking method where we defined four hats and used them to guide our brainstorming directions: white for objective facts, green for creativity and new idea, yellow for strength of an idea, and black for weakness of an idea (De Bono, 1985). Trauma team members including a nurse, a pharmacist, an advanced practice provider, a trauma surgeon, and an emergency medicine (EM) physician participated in this first session.

Design Thinking Session 2: Prune the Future In the second session, we worked based on an activity named “Prune the Future” from the Health Design Thinking book (Ku & Lupton, 2020), where participants were asked to write down their opinions about the current state and the future state of specific statements on each of the four focus areas – workflow, interruptions and Interruptions, sensory factor, and technology integration. This helped understand what aspects of the physical environment currently work or do not work for them in the trauma room and to learn what design ideas participants wish to incorporate in the future trauma rooms. A nurse, an EM tech, a surgeon, an EM physician, and a respiratory therapist participated in this session.

Sessions

Participants

Roles

Design Thinking: : Six Hats of Thinking Sample Question: How might we accommodate observers in a trauma room without disturbing the workflow? Physical Environment Solution 1

Weaknesses

Solution 2

Solution 1

Solution 2

• Design an area forobservers (e.g., aroom next to traumabay)

• Incorporate alcove, booth, or elevated area with view over trauma bay

• Stream the trauma procedures live

• Record the trauma procedures

• Trauma staff can think and act more efficiently

• Eliminates distraction

• Allows for better crowd control by providing the observers with live updates outside the room

• Allows for continued education of student observers

• Allows for better crow dcontrol by providing the observers with recorded procedures that can be watched outside the room later

• Limits communication

• The incoming noise from the designated area could be a problem

• Security risk and potential breach of confidentiality

Solutions

Strengths

Equipment

• Staff could feel pressured when they are under the scrutiny of the observers

• Could introduce tripping hazard

• Separate rooms could be costly • Observers need to be out of the immediate patient area

• Observers need to be out of the immediate patient area

Current State

Design Thinking: : Six Hats of Thinking Sample Question: How might we improve communication among trauma room staff through information displays? Technology – Information Display Solution 1

Solution 2

Solution 3

• Larger and clearer monitors at head and foot of the bed

•Ceiling mounted monitor

• Multiple display screens or computers

• Toggle options to choose and prioritize what information to display

• Multiple display can provide staff equal visibility to patient info and display scan aids can help treat patient more quickly

• Having toggle options can eliminate unnecessary monitors by combining them

• Staff can get tired when moving around to look at screens that are too big

• Difficult to use, since staff cannot look away from patient

• Possible downfalls when displays malfunction

• Possible downfalls on monitors operations

• Not everyone can see or have equal visibility to monitors

• Need for extra monitors to display information such as: team members, timers for procedures, patient info and history, glidescope, and electrocardiogram

• Protocol is needed regarding priority ofthe information

Solutions

Strengths

Weaknesses

Current State

Solution 4

Design Thinking: Prune the Future Workflow Sample Prompts Locating the best spot for sink to enhance work efficiency

Current State

Future State

• Should always be available but not obtrusive

• Two on opposite walls

• One in one side of the room

• Outside the room

• Near exit or out of the way

• One shared sink for two rooms

• Unnecessary sink in the room • Hands free activation

Optimizing access tomedical airs and suctionsin the room to enhanceworkflow

Increasing visibility of nurse to case/patient to better support documenting information

• Medical air and suction at the head of the bed

• Air and suction in the same location

• Boom/headwall for medical airs

• Gas hose and suction could come from ceiling-mounted tower

• Air and suction on one boom

• Outlets could come from beneath the surgery table

• Scribe nurse on portable computer

• Elevated platform for scribe nurse

• Two-step procedure to chart info: one nurse writes down on paper and other nurse will finalize into computer • Nurses not able to see the case easily • Boom is obstructive, not easy to move

Design Thinking: Prune the Future Sensory Factors Sample Prompts Improving lighting systems

Current State

Future State

• Lights are usually bright LED

• Ability to control the light and the color of the room

• Lightings usually have simple on/off setting

• More lighting controls over the room and equipment

• Lighting options are limited

• Dimmer and warmth settings for overhead lights

• Lights can only get dimmed or on/off

Reducing problems with hearing the EMS report or the trauma leader

• Critical info by EMS could be missed due to ambient noise • Flat surfaces amplify echo

• Telecommunication and pre-arrival transition of patient’s information • Using more acoustic and sound-absorbing material

• Noise is an issue for patient and care providers • Critical order by trauma team leader could be missed due to ambient noise

• Designated report area with microphone and local amplifier

Technology Integration Utilizing technology for decontaminating and cleaning purposes Reducing the clutter of cords and cables in the trauma room

• Housekeeping has to clean and decontaminate each room, turnaround time is dependent on the number of staff • UV decontamination requires additional equipment

• Clutter and cords always get tangled • Cable spaghetti is an ongoing issue

• Built-in LED UV lighting with spectrum • Cleaning robots • Ceiling technology for decontamination

• Wireless physiologic monitor technology (is already available just not widely used) • Wireless monitoring • Oxygen/suction built into patient cart

Design Thinking: Prune the Future Disruptions & Interruptions Sample Prompts

Improving accessibility to supply storage

Optimizing the number and type of equipment in the room

Current State • Cabinets are on one side of the room

• Ability to control the light and the color of the room

• Access to supplies via built-in cabinets which can be daunting to look through

• More lighting controls over the room and equipment

• Equipment often congested in a corner, of different sizes and mobility

• Telecommunication and pre-arrival transition of patient’s information

• Equipment cords become tangled

• Using more acoustic and sound-absorbing material

• Rarely used equipment in the room

• Designated report area with microphone and local amplifier

• Dimmer and warmth settings for overhead lights

• Sharing equipment between bays

• Patient has to be moved and repositioned for each type of imaging which delays care

Minimizing imaging related disruptions

Future State

• Imaging techs needing to get x-ray board underneath patient • Equipment such as x-ray machines brought into rooms

• Built-in LED UV lighting with spectrum • Cleaning robots • Ceiling technology for decontamination

• Portable x-ray machine

RESEARCH-INTEGRATED DESIGN PROCESS

DESIGN VARIATIONS

Design Variations Master of Healthcare Design students developed three design variations for a safer and more efficient Level I trauma room based on three eras – the current state, 25 years from now, and 50 years from now. The variations presented solutions ranging from those as an immediate response to those aligned with a futuristic vision. The design assignments helped students think critically about the different facets of users’ needs in the complex context of trauma rooms and develop design solutions for a complete Level I trauma room. The goal was for this project to not only address today’s issues in Level I trauma rooms, but also present possibilities for a sophisticated future trauma room. The studio designs ideas included innovative considerations related to user experience, safety, human factors, and flexibility for future changes in the environment.

Design Variation I: Current State The current state or 2021 trauma room variation is designed based on the existing technology available in the market and comments received from clinicians in focus groups and design thinking sessions. To achieve enhanced workflow, cabinets are provided on both sides of the room to allow for equal and quick access to supplies. A monitor that live streams procedures is provided for the scribe nurse to enhance their visibility to the patient while documenting. Doors connecting to the next rooms are provided to help staff members attend patients in two adjacent rooms if need be. To help reduce interruptions and disruptions, color-coded floor boundary is implemented as a reinforcement for trauma team to remain cognizant of their positioning and location. Anteroom is incorporated as well for more effective crowd control by keeping the observers in this area. Observers will remain in a designated area within the anteroom and observe case through a wall-mounted live stream monitor. The anteroom also acts as a buffer between the trauma room and the hallway to reduce noise travel and temperature fluctuation in a vestibule-like space. For technology integration, overhead monitors are provided on three sides of the room where trauma team members can have a better view to patient information and other case relevant information (e.g., vitals, patient information, trauma procedure, trauma team members information). Additionally, two wall-mounted monitors are provided on each side of room to display imaging results (e.g., x-ray, CT scans). To enhance control over sensory stimuli, control panels are provided in different locations in the trauma room where team members can easily access and adjust the lighting and temperature of the room. Lastly, this modular room layout provides flexibility for future expansion.

Design Variation I I Design Variation Workflow

Technology Integration X-ray monitors on both sides: Easy access to patient x-ray results Streaming monitor for observers: Streaming trauma case

Cabinets on both sides: Easy access to resources

Monitor for scribe nurse: Enhanced visibility to patient

Connecting door to next room: Enhanced flexibility

Interruptions & Disruptions

Sensory Factors Wall-mounted control panels: Lighting and temperature control

Anteroom with doors: Noise and temperature control

1 2

Color-coded floor boundaries: Crowd control Anteroom: Crowd control

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Design Variation I

Design Variation I: Interior Renderings

Design Variation II: 25 Years into the Future This variation of trauma room was designed for 25 years from now. This design focuses on the technological advances in the next 25 years by tracking today’s technological trends and their probable impacts on the future of trauma rooms. One of the main features is the advanced medical boom focused on enhancing team collaboration and individual clinician experiences based on their preferences. For example, if the trauma surgeon is left-handed, surgical lights and medical column will position themselves in order to provide a more convenient workplace. Another feature is scenario-based device positioning. Given the fact that each patient needs specific care requirements, the lighting setting and medical column should be adjusted to streamline care based on the condition of the patient and prior to the patient’s arrival. This design also presents a novel way of patient transfer from EMS stretcher to trauma room stretcher and in imaging procedure, since it may cause injuries. Some other features include 3D printing device consideration for casting, customized cart arrangement, color-coded area, and anteroom.

Design Variation II

Design Variation II Technology Integration Advanced medical boom:

Workflow 1

Customized based on preset preferences Position device based on injury

Interactive Monitors:

Automated sterilization process:

Touchless interactions

Automatic washing hand station: Touchless interactions

Interruptions & Disruptions

Sensory Factors Anteroom with doors: Noise and temperature control

Doors connecting adjacent rooms: Enhanced flexibility

Patient transfer: Safe patient transfer from EMS to trauma stretcher

Color-coded floor boundary: Crowd control

Design Variation II

Design Variation II: Interior Renderings

Design Variation III: 50 Years into the Future This 2071 trauma room variation is the most conceptual design process that drastically redefines care delivery in an advanced technological context. The room consists of two spatial layers: the inner layer of human-based onstage, the actual trauma room, and the outer layer of machine-based offstage, which refers to the whole futuristic support areas. The main idea was to incorporate advanced technology controlled by artificial intelligence for on-demand delivery of what clinicians need. Walls are considered the stationary base for the floating delivery units working based on the levitation technology that allows them to adjust and reposition themselves related to clinicians’ needs. Integrated Imaging unit into the headwall provided a one-stop shop trauma room that would enormously support the trauma workflow and reduce patient safety hazards due to transportation. Additionally, the trauma bed is completely redefined to act as an adjustable ducting system coming out of the floor surface and provide all the critical accessibilities such as power outlets, medical gases, suctions, and hoses. Furthermore, the concept of communication was transformed into holographic and virtual abilities where physical displays are no longer necessary. Clinicians have access to vital information through the augmented reality gadgets and can run different treatment scenarios prior to patient arrival. Advanced technology enabled us to assign documenting tasks to artificially intelligent systems and reduce disruptions due to the unnecessary crowd. The entry section of the room is dedicated to the external individuals where they can watch the live stream of patient treatment. Noise cancelation technology and anti-shadow lighting systems.

Design Variation III

Workflow 1 Floating delivery units:

Reduce travel distance Improve accessibility to supplies Decrease number of staff

Technology Integration Integrated imaging unit:

Eliminate patient transportation Enhance imaging process

Advanced Trauma bed:

Provide critical accessibilities Enhance patient transportation Control patient temperature

Accelerate preparation process

Interruptions & Disruptions

Sensory Factors Virtual noise/visual barrier:

Improve control over sensory factors Enhance physical communication Support privacy requirement

Noise cancelation technology: Improve noise control Enhance critical communication

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2 Automated PPE dispensary:

1 Virtual projection:

Support crowd control Enhance educational purpose

2 Anteroom:

Support crowd control

Design Variation III

Design Variation III: Interior Renderings

RESEARCH-INTEGRATED DESIGN PROCESS

MOCK-UP CONSTRUCTION

Mock-Up Construction Physical mock-ups are known to effectively communicate design ideas to end-users and are increasingly being used in the healthcare facilities design process to support and validate design decisions. As such, building a physical mock-up was incorporated in the studio to provide an opportunity for end-users to engage and evaluate the design ideas. After building the physical mock-up, clinicians were invited for trauma scenario-based simulations and design evaluations. Given the feasibility of implementing the design ideas, we built a full-scale mockup of Variation I – the current state (year 2021). Our students and research assistants built a low-fidelity physical mock-up using falcon boards and foam boards. The physical mock-up was built in Kent State University’s Design Innovation Hub.

Mock-Up Construction Process

Completed Physical Mock-Up

RESEARCH-INTEGRATED DESIGN PROCESS

SCENARIO-BASED SIMULATIONS

Scenario-Based Simulations It is crucial for healthcare designers to evaluate the impact of key design decisions prior to the facility construction to ensure operational efficiencies, safety, improved experience for clinicians, patients, and visitors. Clinicians often find it challenging to understand design strategies or picture the impact of design on their work only based on layouts, perspectives, or architectural drawings. Therefore, running scenario-based simulations in a full-scale physical mock-up is an effective way to evaluate design strategies from clinicians’ perspective. Simulation-based mock-up evaluation involves testing various design elements or strategies by simulating clinical scenarios or enactment of relevant tasks. The research team developed a structured template to evaluate the design elements under study in the physical mock-up of the current state. The template included the list of the design elements along with the evaluation criteria for each design element. Clinicians (e.g., surgeons, nurses, EM physicians) from Cleveland Clinic Akron General were invited to form a team and run the simulations. A total of three trauma scenarios were conducted. – a gunshot wound incident , a fall incident, and a car accident with a pregnant woman. The simulations were video recorded to allow the research team conduct post-simulation analysis of the interactions between clinicians and the physical environment. Each simulation was followed by an open-ended discussion and individual interviews with clinicians.

Scenario-Based Simulations Blanket warmer & Blood Refrigerator Ultrasound machine Storage cabinet

Storage cabinet Medical column

Blood infuser

IV pole

X-ray display

Portable ultrasound

Portable ventilator

Coded cart

Surgical light

Crash cart

Scribe station

Crash cart

Pyxis

Pathway door

Observation display

Pathway door PPE storage

Handwashing station

Scenario-Based Simulations

Scenario-Based Simulations Design elements evaluated • Cabinets on both sides • Carts on both sides • Blood bank at the corner of the room • Countertop as a work surface

Design strategies

Sample interview questions

• Locate adequate cabinets and carts on both sides of the trauma room

• How accessible were the location of cabinets and carts?

• Locate two work surfaces within the trauma room

• Could you please give your feedback about the number and size of the shelves?

• Flexible furnishings

• Computer on wheel (COW) for scribe nurse

• How often during the procedure would you need to use the carts? • Did countertop work as a work surface for staff? • How effective was the scribe nurse’s location?

• Angled display monitors on sidewalls • Display for the scribe nurse • Display in the anteroom • Anteroom • Color-coded flooring

• Locate five displays on both sides of the walls, one close to the scribe nurse and one in the anteroom to enhance communication and reduce repetitive questions • Room zoning and planning for better crowd control

• What did you think about the location of angled display monitors?

• Establish clear functional room zoning to reduce flow disruptions

• Does the location of the anteroom facilitate an easy movement of the patient in and out of the room?

• Locate handwashing station in the anteroom • Room size • Control panels • Blood bank • Doors

• What types of information would you like to see on the angled displays?

• Do you need to use the handwashing station during some procedures? • Providing light and temperature control panels on both sides of the walls and the headwall. • Adequate square feet for each zoning

• How was the size of the room? • In which scenario, you wish you could change the size of the room? • How was the location of light control panels? • Was the number of control panels sufficient? • How was the width of the sliding doors? Did you find it big enough?

Design Elements Evaluations Cabinets: Strength: Cabinets on both sides of room provide equal access to supplies Suggestion: Larger cabinets to provide more storage space

Carts: Strength: Carts on both sides of room allows for easy access to supplies Suggestion: Color-coded carts with transparent glass doors may improve access to supplies

Design Elements Evaluations Workstation on Wheel:

Strength: Mobile workstation for scribe nurse allows greater maneuverability and visibility to patient Suggestion: Consider elevated platform for scribe nurse for better visibility to patient

Countertops:

Strength: Height appropriate worksurfaces support nurses and pharmacists’ tasks Suggestion: Countertops could be smaller and only on one side of room to save space for more cabinets

Design Elements Evaluations Wall-Mounted Monitors:

Strength: Multiple monitors on both sides improve accessibility to essential information Suggestions: Have fewer but larger monitors Display live stream from patient’s top view

Anteroom:

Strength: Improves crowd control and provides space to accommodate external individuals and equipment Suggestions: Remove door between anteroom and trauma room for a more efficient workflow Provide storage area for clinician’s clothes and lead aprons

NEXT STEPS

Next Steps In phase two and phase three of the project, the patient safety learning lab focused on designing variations of a safer and more efficient trauma room. A graduate studio in Kent State University’s Healthcare Design program was dedicated to designing a level I trauma room. The design studio utilized research in the design process to help students base their design decisions on credible evidence. The research portion of the studio included design thinking sessions. Three variations of trauma rooms were developed for three eras (the current state, 25 years into the future, and 50 years into the future). A physical mock-up of the current state variation was built. Scenario-based simulations were conducted by Clinicians to help evaluate the design elements. The design evaluations helped identify the best strategies moving forward and informed the steps for design refinements. The next steps of the project include multiple research activities, as we enter the Implementation phase or phase four of the project. Given the iterative nature of the design process, we plan to refine the designs and seek clinicians’ feedback as evaluation similar to phase two and phase three. 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.

Next Steps 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.

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. The second year of the project continued during the pandemic. The momentum built in the first year along with the experience gained to keep our research team safe kept the team moving forward with the next steps of the research project. 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 thank Mr. Peter Bohan, who acted as a Co-Instructor for the Healthcare Design studio, guiding the students throughout the semester based on his extensive experience as an architect. We also thank the Design Innovation Hub for generously providing us with space and resources to build a physical mock-up and displaying it. 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

ADVISORY COMMITTEE

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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.

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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.

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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.

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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.

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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.

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References 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. Bayramzadeh, S., & Aghaei, P. (2021). Technology integration in complex healthcare environments: A systematic literature review. Applied ergonomics, 92, 103351. Bayramzadeh, S., Ahmadpour, S., & Aghaei, P. (2021). The relationship between sensory stimuli and the physical environment in complex healthcare settings: A systematic literature review. Intensive and Critical Care Nursing, 67, 103111. Bayramzadeh, S., Anthony, M. K., Sterling, M., & O’Donnell, K. (2021). The Role of the Physical Environment in Shaping Interruptions and Disruptions in Complex Health Care Settings: A Scoping Review. American Journal of Medical Quality, 36(6), 449458. Bayramzadeh, S., Joseph, A., Allison, D., Shultz, J., Abernathy, J., & Group, R. O. S. (2018). Using an integrative mock-up simulation approach for evidence-based evaluation of operating room design prototypes. Applied ergonomics, 70, 288-299.

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Hicks, C., & Petrosoniak, A. (2018). The human factor: Optimizing trauma team performance in dynamic clinical environments. Emergency Medicine Clinics, 36(1), 1-17. Holden, R. J., Carayon, P., Gurses, A. P., Hoonakker, P., Hundt, A. S., Ozok, A. A., & RiveraRodriguez, A. J. (2013). SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics, 56(11), 1669-1686. 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. 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. Ku, B., & Lupton, E. (2020). Health design thinking: Creating products and services for better health. MIT Press.

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.

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.

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

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

De Bono, E. (1985). Six Thinking Hats. London: Penguin Books.

Sarcevic, A. (2009, May). A study of collaborative information behavior in trauma resuscitation. In Collaborative Information Behavior Workshop at Group (pp. 1-4).

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