The Future of Cognitive Aids Implemented During Critical Events

Author: Larry M. Silver MD

ASA Monitor 11 2015, Vol.79, 40-42.

Larry M. Silver, M.D. is Private Practice Anesthesiologist, Coastal Anesthesia Medical Associates; Medical Product Developer for Tahoe Institute of Rural Health Research, San Luis Obispo, California.

Acute care cognitive aids (ACCAs) are tools used by clinicians to deliver emergent treatment to patients with acute medical problems. ACCA tools have traditionally included manuals, checklists, protocols and other written documentation. Today’s digital technology, including tablets and smartphones, promises faster access and better outcomes.

There is growing interest in these ACCAs as clinicians confront the increasing number and complexity of medical critical care and non-critical care protocols and algorithms. Clinicians are required to perform algorithm-driven medical tasks with a high degree of accuracy under highly stressful scenarios. The rapid paced critical care environment does not allow practitioners time to review or refresh their memory of these algorithms. The critical nature of these events prohibits the use of textbooks, the Internet, journals and other traditional cognitive aids. Rapid access to this information is critical.

Currently there are approximately 25-plus critical, semi-critical and pediatric care algorithms in common use. The algorithms are typically based on “best practice guidelines” that were developed and peer-reviewed by nationally recognized authorities, including the American Heart Association, ASA, American College of Emergency Physicians and others.

For example, the treatment algorithm “Malignant Hyperthermia” is made up of a sequential linear and branching logic series of tasks that are both diagnostic and therapeutic in nature.

The Age of Digital Cognitive Aids (DCAs) Emerges

Traditionally, clinicians learned important pathways, protocols and algorithms during their medical training. This meant memorizing and applying a fixed body of knowledge in a fast-changing medical environment. Physicians and allied professionals realize that memorizing an expanding body of knowledge is simply not a sustainable model. A cultural change has come to educators and clinicians who now readily accept cognitive aids as a tool.

Medical knowledge and its respective databases have grown exponentially. It is beyond human capability to fully recall and apply all specific treatment protocols and algorithms during high-stress “code” events. A recent article shows reduced performance as a function of time: “Time since the last ACLS training was found to be an important predictor of correct management of simulated arrest … Successful management occurred 71% @ <6 months, 30% @ <2yr and 0% @ >2 years since ACLS course.”¹  Critical events occur unexpectedly in daily practice. Crucial treatment information, often not regularly reviewed or practiced by the clinician, must suddenly be brought to mind. To date, no effective mobile platform exists to deliver interactive DCAs to the clinical environment.

Digital technology has exploded in medicine. Today, computers are playing a more integral and vital role in daily clinical practice. Faster processors, massive database capability, touchscreen interfaces, wireless technology and the Internet are here to stay. Modern medicine could not exist without these tools. It may be accessing an electronic health record (EHR) system for patient data, utilizing a Web-based clinical decision support (CDS) system such as UpToDate or a personal device such as a smartphone or iPad for access to Epocrates. We can now anticipate the rapid development and implementation of DCAs into the domain of ACCA.

The future of checklists and cognitive aids in medicine: interactive software deployed on tablets, large-screens and Google Glass.

A Stanford Computer Science Ph.D. research project, with Stanford HCI and the Anesthesia Informatics and Media Lab. Courtesy of Larry Chu, M.D.www.youtube.com/watch?t=24&v=UoMHzX36Gmg.

The Face of New Technology

The development of cognitive aids in the acute care setting has been discussed extensively in the recent literature (Marshall, 2013). It is now well established that the design elements must include a platform that is complete, efficient to use, well organized and relevant to the intended users. The design must be built with clinician usability during a high-stress environment as the first priority.

Hurdles Existed for Implementation of Acute Care DCA Technologies

Previous authors have described various implementation strategies for ACCAs.²  Although the challenge of gaining widespread acceptance and usage is formidable, there is a road map to success. Goldhaber-Fiebert proposes a sequence of “Create, Familiarize, Use and Integrate.” This strategy promotes familiarity with these tools before actual use is required. This would most likely require a top-down distribution model where all providers within a hospital system are issued the same tool and receive their training in an organized and uniform fashion. Such consistency would increase awareness and acceptance by clinicians. Frequent use, review and integration as an educational tool at an institutional level would be recommended.

The New Interactive DCA

During the past several years, my team and others have developed innovative new DCA technologies for use during critical medical scenarios. These platforms comprise DCAs that deliver 25-plus algorithms to the point of care on tablets and smartphones. The emergency manual by the Stanford Anesthesia Cognitive Aid Group (SACAG) provides downloadable content that has been extensively studied in their clinical simulator environment. Children’s Hospital of Philadelphia has developed a selective pediatric DCA platform called “Pedi Crisis.”

The Protocols & Algorithms for Critical Events, or “PACE,” platform is a new and fully interactive DCA that utilizes widely recognized authoritative content (AHA, SACAG and others). The software is Wi-Fi independent and runs on the commonly used operating systems Android and iOS. It is fully interactive with the action item guiding the clinician through each diagnostic and therapeutic step. It runs on a digital platform, records each event as discrete data and generates highly useful output. The output is HL-7 based, HIPAA-compliant, stored on a central server and compatible with interfacing to major EHR systems through an API.

Potential Environments for Interactive DCA Use

Historically, ACCAs have been created in relative isolation for use in anesthetic emergencies, pediatric emergencies and emergency department settings. The applications were designed with their focus being oriented to a given clinical setting. This resulted in static paper-based documents being posted or placed at specific locations such as O.R.s or emergency trauma rooms. The development and implementation of traditional CDS systems have also evolved along the same lines as enterprise EHR systems. Both of these are inherently coupled to the computer client user location, thus limiting their rapid access and mobility. Prior attempts at DCAs failed as they were tied to a point-and-click computer interface in fixed locations, thereby severely inhibiting rapid deployment at point of care.

New interactive DCA technologies facilitate use in virtually any setting, including O.R.s, emergency departments, urgent care facilities, ICUs, ambulatory surgery centers and physician offices with independent surgical suites. The ubiquitous presence of smartphones and tablets is the foundation for their widespread application. The ideal user would be any individual who is already trained in the clinical content they are accessing. They would potentially be from all medical specialties and with various levels of training. The DCA is suitable as a “pre- and post-crisis” educational tool and as a real-time “during crisis” clinical tool. It should be designed for use by an individual managing a crisis or for use by a reader or assistant during the team approach.

The Presence of Cognitive Aids Can Directly Affect Performance

The analytics for successful implementation of ACCAs is in its infancy and no definitive literature has established this methodology. Their analogous use in aviation and nuclear power plant safety protocols has been extensively evaluated and has been shown to be consistently valuable. The early consensus among subject matter experts points towards a positive result from use of well-designed and effectively implemented ACCAs in medicine. It is likely that their use will improve performance.^2,3  We now find the recommended use of ACCAs is finding its way into the guidelines of hospital and surgery center accreditation organizations.⁴  The interactive DCA platform is sure to lead this frontier as it is highly mobile and easy to refine.⁵ 

The Future of Medical DCA Design and Implementation Platforms

As we move forward, we anticipate these cognitive aid platforms being adapted to newer and more progressive user devices as those technologies become available. We also see developing additional functionality that will allow interactive DCAs to guide and document the entire code/critical event process. This could include a GUI-based, fully interactive “code record” sheet on a central display allowing for capture of all the vital clinical information that occurs during these events.

The data output from interactive DCAs is easily interfaced into existing enterprise EHR systems as a continuity of care document, or CCD, making it a permanent part of the medical record. This would fill the current “void” in real-time data capture by EHRs during a critical event. In the near future, we will be able to data-mine the anonymized aggregate discrete data generated by use of each algorithm. This will allow for a secondary epidemiologic application of the DCAs. We can analyze the efficacy of these established algorithms and, therefore, develop further evidence-based modifications to the medical content. This data mining will also benefit user subsets, such as large hospital systems, as they can analyze their unique performance and results.

References:

Anesthesiology, clinical investigations. 1992 Anesthesiologist’s management of Simulated Critical Incidents. Schwid, Howard MD, O’Donnell, Daniel PhD.

Goldhaber-Fiebert SN, Howard SK . Implementing Emergency Manuals: Can Cognitive Aids Help Translate Best Practices for Patient Care During Acute Events. Anesthesia & Analgesia 2013; 117:5:1149–61

Haynes AB, Gawande AA et al. Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–9

2013 Accreditation Handbook for Ambulatory Health Care. Skokie, III Accreditation Association for Ambulatory Health Care. 2015:43,48, 51.

Marshall S . The Use of Cognitive Aids During Emergencies in Anesthesia: A Review of the Literature. Anesthesia & Analgesia 2013; 117:5:111162–71