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TADAA - Enabling Continuous Improvement for Anaesthetists

TADAA - Enabling Continuous Improvement for Anaesthetists



Bryan Houliston

Bryan Houliston
AURA Lab, Auckland University of Technology
(P31, 1/10/09, Opus Room, 11.28)



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    TADAA - Enabling Continuous Improvement for Anaesthetists TADAA - Enabling Continuous Improvement for Anaesthetists Presentation Transcript

    • TADAA Towards Automated Detection of Anaesthetic Activity Bryan Houliston Aura Laboratory
    • TADAA Outline
      • Radio Frequency Identification
      • Adaptive Temporal Smoothing
      • Lateration-by-Attenuation Triangulation
      • Hybrid Generative-Discriminative Machine Learning
      • Self Organising Maps
      • Switching Hidden semi-Markov Models
      • Receiver Operating Curve Analysis
    • TADAA Enabling continuous improvement for anaesthetists Bryan Houliston Aura Laboratory
    • Agenda Introduction 1 Task analysis and TADAA 2 Key abilities for anaesthetists 3 Enabling improvement 4 Conclusion 5
    • Introduction
      • Healthcare: “learning comes in batches, like slow and infrequent trains, not like continuous FedEx deliveries” (Andy Grove, quoted in The Economist, 2009)
      • Anaesthesia: “something then nameless and profound that even today we understand but partly” (Eger, 2006)
      • “ Extreme approximation of death” (Euliano, 2004)
      • “ Every complication can cause lasting harm. Therefore deviations from the norm must be recognized promptly” (Aitkenhead, 2007)
    • Traditional Focus on Patient Monitoring patient Understanding anaesthetic state Closed loop systems (Simanski, 2008) Sensors & alarms (Jones, 2001) Knowledge bases
    • Adverse Events (Davis, 2003)
      • 58% of AEs occur during anaesthesia
      • 35% are ‘highly’ preventable
      • Recording
      • Access to information
      • Standards and adherence
      • Communication
      • Organisational culture
      ‘ System’ factors 49%
      • With peers
      • With specialists
      Lack of consultation 36%
      • Professional knowledge
      • Technical skills
      Lack of education 27%
    • Emerging Focus on Anaesthetist Monitoring anaesthetist Understanding anaesthetic activity Simulator training (Dalley, 2004) Incident reports (Smith, 2006) Checklists (Hart, 2005)
    • Task Analysis
      • “ A scientific description of task patterns and workload would aid in our understanding and provide a more rational basis for improvements” (Weinger, 1994)
      • Studies are ‘slow and infrequent’
        • Labour intensive
        • Create privacy issues for patients, other staff
      • And data could be more ‘scientific’
        • Observers can be distracted, obstructed
        • Inter- and intra-study consistency
        • Small sample sizes
    • TADAA Towards Automated Detection of Anaesthetic Activity Viewer module Repository module Recorder module
    • How Will TADAA Help ?
      • How could ongoing, real-time, automated task analysis enable anaesthetists to practice continuous ‘FedEx’ learning and improvement ?
      • What are the most important abilities for anaesthetists ?
      • Three perspectives: “We owe it to our patients, our colleagues, and ourselves to strive for excellence” (Smith, 2009)
    • Patients Want… (Davis, 2003)
      • Less chance of AEs
      • Recording
      • Access to information
      • Standards and adherence
      • Communication
      • Organisational culture
      Better ‘systems’
      • With peers
      • With specialists
      Better consultation
      • Professional knowledge
      • Technical skills
      Better education
    • Surgeons Want … (Vitez, 1998) Calmly manage a crisis Quick emergence Familiar with procedure Quick induction Correct intubation Timely starts Correct monitor placement Short turnaround Communicate with OR staff Good patient relationship Knowledge & skills Less waiting around Communication
    • Other Colleagues Want…
      • Administrators want good records
        • Costs (Canales, 2001)
      • Post-op Nurses want good records
        • Possible complications, Treatment plans
      • Technicians, trainees want communication
        • Plan for procedure, Clear instructions
        • Teaching
    • Anaesthetists’ ‘Core’ Work… (Larsson, 2003) Co-ordinator Technique (Knowledge & skills) Patient (Communication) OR team (Consultation) Planning & monitoring (Recording)
    • Three Most Important Abilities
      • Recording
        • Data > Information > Knowledge
        • “ Tedious” aspect of work (Euliano, 2004)
        • Delays lead to inaccurate data (Aitkenhead, 2007)
        • Incidents under-reported (Smith, 2006)
      • Communication
        • Poor timing 46% (Lingard, 2004)
      • Knowledge & skills
    • TADAA Automates Recording Drugs drawn up but not given Fixing, locating equipment With preceding activity Drug administration, Intubation, etc
      • Recorder module…
      Events currently recorded manually Events not currently recorded Automated incident reports Reduces ‘tedious’ work More time for art, service, samaritan-ness More timely, accurate, consistent, complete data Reduce onus to ‘dob in’
    • TADAA Supports Communication Progress of procedure Workload assessment Progress against plan Workload assessment Progress of procedure Progress of turn around
      • Viewer module as new channel
      Patients’ families, Surgeons OR team Co- ordiniators Automate progress updates Reduce interruptive timing Monitor developing emergencies Schedule relief
    • TADAA Builds Knowledge Synthesise ‘the norm’ for procedure Identify tacit knowledge, unconscious behaviours Review unfamiliar procedure, patient condition
      • Repository module…
      Exemplar procedures Analyse by procedure type Analyse by anaesthetist Familiarity with procedure Recognise deviations from ‘the norm’ Awareness of own strengths, weaknesses Tacit knowledge of experts
    • Conclusion
      • Task analysis offers
        • Deeper understanding of anaesthesia, Rational basis for making improvements
        • Recognizing deviations from the norm
      • But only if ongoing, real-time, ‘scientific’ data
      • TADAA supports continuous improvements of three key abilities
        • More automated recording
        • Communication of progress, workload
        • Building knowledge
    • Conclusion
      • “ We should consider methods of recording the behavioural traits and practical unwritten knowledge exhibited by excellent anesthesiologists, and explore means of making these more widely visible” (Smith, 2009)
      • “ When you get [Health IT] right, a doctor is no longer limited by lessons of personal experience” (Dr Craig Smith, quoted in The Economist, 2009)
    • References
      • Aitkenhead AR, Smith G, Rowbotham DJ. Textbook of Anaesthesia . Fifth ed: Elsevier Limited 2007.
      • Canales MG, Macario A. Can peri-operative quality be maintained in the drive for operating room efficiency? An American perspective. Best Practice and Research in Clinical Anaesthesiology. 2001;15(4):607-19.
      • Dalley P, Robinson B, Weller J, Caldwell C. The Use of High-Fidelity Human Patient Simulation and the Introduction of New Anesthesia Delivery Systems. Anesthesia & Analgesia. 2004;99(6):1737-41.
      • Davis P, Lay-Yee R, Briant R, Ali W, Scott A, Schug S. Adverse events in New Zealand public hospitals II: preventability and clinical context. New Zealand Medical Journal. 2003;116(1183).
      • Anonymous. Flying Blind. The Economist . 2009:S6-S8.
      • Eger EI, Sonner JM. Anaesthesia defined (Gentlemen, this is no humbug). Best Practice & Research Clinical Anaesthesiology. 2006;20(1):23-9.
      • Euliano TY, Gravenstein JS. Essential Anaesthesia From Science to Practice . Cambridge, UK: Cambridge University Press 2004.
      • Hart EM, Owen H. Errors and Omissions in Anesthesia: A Pilot Study Using a Pilot's Checklist. Anesthesia and Analgesia. 2005;101:246-50.
      • Jones RW, Harrison MJ, Lowe A. Computerised anaesthesia monitoring using fuzzy trend templates. Artificial Intelligence in Medicine. 2001;21(3):247-51.
    • References
      • Larsson J, Holmstrom I, Rosenqvist U. Professional artist, good Samaritan, servant and co-ordinator: four ways of understanding the anaesthetist's work Acta Anaesthesiologica Scandinavia. 2003;47(7):787-93.
      • Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Quality and Safety in Health Care. 2004;13:330-4.
      • Simanski O, Janda M, Schubert A, Bajorat J, Hofmockel R, Lampe B. Progress of automatic drug delivery in anaesthesia - The 'Rostock assistant system for anaesthesia control (RAN)'. International Journal of Adaptive Control and Signal Processing. 2008;22.
      • Smith AF. In Search of Excellence in Anesthesiology. Anesthesiology. 2009;110(1):4-5.
      • Smith AF, Goodwin D, Mort M, Pope C. Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting. British Journal of Anaesthesia. 2006;96(6):715-21.
      • Vitez TS, Macario A. Setting Performance Standards for an Anaesthesia Department. Journal of Clinical Anaesthesia. 1998;10:166-75.
      • Weinger MB, Herndon OW, Zornow MH, Paulus MP, Gaba DM, Dallen LT. An Objective Methodology for Task Analysis and Workload Assessment in Anaesthesia Providers. Anesthesiology. 1994;80(1):77-92.
    • Thanks to: Dave Parry and Alan Merry Staff at Advanced Clinical Skills Centre HamIT Tracient Bryan Houliston Aura Laboratory