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TADAA - Enabling Continuous Improvement for Anaesthetists


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

Published in: Health & Medicine
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TADAA - Enabling Continuous Improvement for Anaesthetists

  1. 1. TADAA Towards Automated Detection of Anaesthetic Activity Bryan Houliston Aura Laboratory
  2. 2. TADAA Outline <ul><li>Radio Frequency Identification </li></ul><ul><li>Adaptive Temporal Smoothing </li></ul><ul><li>Lateration-by-Attenuation Triangulation </li></ul><ul><li>Hybrid Generative-Discriminative Machine Learning </li></ul><ul><li>Self Organising Maps </li></ul><ul><li>Switching Hidden semi-Markov Models </li></ul><ul><li>Receiver Operating Curve Analysis </li></ul>
  3. 3. TADAA Enabling continuous improvement for anaesthetists Bryan Houliston Aura Laboratory
  4. 4. Agenda Introduction 1 Task analysis and TADAA 2 Key abilities for anaesthetists 3 Enabling improvement 4 Conclusion 5
  5. 5. Introduction <ul><li>Healthcare: “learning comes in batches, like slow and infrequent trains, not like continuous FedEx deliveries” (Andy Grove, quoted in The Economist, 2009) </li></ul><ul><li>Anaesthesia: “something then nameless and profound that even today we understand but partly” (Eger, 2006) </li></ul><ul><li>“ Extreme approximation of death” (Euliano, 2004) </li></ul><ul><li>“ Every complication can cause lasting harm. Therefore deviations from the norm must be recognized promptly” (Aitkenhead, 2007) </li></ul>
  6. 6. Traditional Focus on Patient Monitoring patient Understanding anaesthetic state Closed loop systems (Simanski, 2008) Sensors & alarms (Jones, 2001) Knowledge bases
  7. 7. Adverse Events (Davis, 2003) <ul><li>58% of AEs occur during anaesthesia </li></ul><ul><li>35% are ‘highly’ preventable </li></ul><ul><li>Recording </li></ul><ul><li>Access to information </li></ul><ul><li>Standards and adherence </li></ul><ul><li>Communication </li></ul><ul><li>Organisational culture </li></ul>‘ System’ factors 49% <ul><li>With peers </li></ul><ul><li>With specialists </li></ul>Lack of consultation 36% <ul><li>Professional knowledge </li></ul><ul><li>Technical skills </li></ul>Lack of education 27%
  8. 8. Emerging Focus on Anaesthetist Monitoring anaesthetist Understanding anaesthetic activity Simulator training (Dalley, 2004) Incident reports (Smith, 2006) Checklists (Hart, 2005)
  9. 9. Task Analysis <ul><li>“ A scientific description of task patterns and workload would aid in our understanding and provide a more rational basis for improvements” (Weinger, 1994) </li></ul><ul><li>Studies are ‘slow and infrequent’ </li></ul><ul><ul><li>Labour intensive </li></ul></ul><ul><ul><li>Create privacy issues for patients, other staff </li></ul></ul><ul><li>And data could be more ‘scientific’ </li></ul><ul><ul><li>Observers can be distracted, obstructed </li></ul></ul><ul><ul><li>Inter- and intra-study consistency </li></ul></ul><ul><ul><li>Small sample sizes </li></ul></ul>
  10. 10. TADAA Towards Automated Detection of Anaesthetic Activity Viewer module Repository module Recorder module
  11. 11. How Will TADAA Help ? <ul><li>How could ongoing, real-time, automated task analysis enable anaesthetists to practice continuous ‘FedEx’ learning and improvement ? </li></ul><ul><li>What are the most important abilities for anaesthetists ? </li></ul><ul><li>Three perspectives: “We owe it to our patients, our colleagues, and ourselves to strive for excellence” (Smith, 2009) </li></ul>
  12. 12. Patients Want… (Davis, 2003) <ul><li>Less chance of AEs </li></ul><ul><li>Recording </li></ul><ul><li>Access to information </li></ul><ul><li>Standards and adherence </li></ul><ul><li>Communication </li></ul><ul><li>Organisational culture </li></ul>Better ‘systems’ <ul><li>With peers </li></ul><ul><li>With specialists </li></ul>Better consultation <ul><li>Professional knowledge </li></ul><ul><li>Technical skills </li></ul>Better education
  13. 13. 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
  14. 14. Other Colleagues Want… <ul><li>Administrators want good records </li></ul><ul><ul><li>Costs (Canales, 2001) </li></ul></ul><ul><li>Post-op Nurses want good records </li></ul><ul><ul><li>Possible complications, Treatment plans </li></ul></ul><ul><li>Technicians, trainees want communication </li></ul><ul><ul><li>Plan for procedure, Clear instructions </li></ul></ul><ul><ul><li>Teaching </li></ul></ul>
  15. 15. Anaesthetists’ ‘Core’ Work… (Larsson, 2003) Co-ordinator Technique (Knowledge & skills) Patient (Communication) OR team (Consultation) Planning & monitoring (Recording)
  16. 16. Three Most Important Abilities <ul><li>Recording </li></ul><ul><ul><li>Data > Information > Knowledge </li></ul></ul><ul><ul><li>“ Tedious” aspect of work (Euliano, 2004) </li></ul></ul><ul><ul><li>Delays lead to inaccurate data (Aitkenhead, 2007) </li></ul></ul><ul><ul><li>Incidents under-reported (Smith, 2006) </li></ul></ul><ul><li>Communication </li></ul><ul><ul><li>Poor timing 46% (Lingard, 2004) </li></ul></ul><ul><li>Knowledge & skills </li></ul>
  17. 17. TADAA Automates Recording Drugs drawn up but not given Fixing, locating equipment With preceding activity Drug administration, Intubation, etc <ul><li>Recorder module… </li></ul>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’
  18. 18. TADAA Supports Communication Progress of procedure Workload assessment Progress against plan Workload assessment Progress of procedure Progress of turn around <ul><li>Viewer module as new channel </li></ul>Patients’ families, Surgeons OR team Co- ordiniators Automate progress updates Reduce interruptive timing Monitor developing emergencies Schedule relief
  19. 19. TADAA Builds Knowledge Synthesise ‘the norm’ for procedure Identify tacit knowledge, unconscious behaviours Review unfamiliar procedure, patient condition <ul><li>Repository module… </li></ul>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
  20. 20. Conclusion <ul><li>Task analysis offers </li></ul><ul><ul><li>Deeper understanding of anaesthesia, Rational basis for making improvements </li></ul></ul><ul><ul><li>Recognizing deviations from the norm </li></ul></ul><ul><li>But only if ongoing, real-time, ‘scientific’ data </li></ul><ul><li>TADAA supports continuous improvements of three key abilities </li></ul><ul><ul><li>More automated recording </li></ul></ul><ul><ul><li>Communication of progress, workload </li></ul></ul><ul><ul><li>Building knowledge </li></ul></ul>
  21. 21. Conclusion <ul><li>“ 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) </li></ul><ul><li>“ 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) </li></ul>
  22. 22. References <ul><li>Aitkenhead AR, Smith G, Rowbotham DJ. Textbook of Anaesthesia . Fifth ed: Elsevier Limited 2007. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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). </li></ul><ul><li>Anonymous. Flying Blind. The Economist . 2009:S6-S8. </li></ul><ul><li>Eger EI, Sonner JM. Anaesthesia defined (Gentlemen, this is no humbug). Best Practice & Research Clinical Anaesthesiology. 2006;20(1):23-9. </li></ul><ul><li>Euliano TY, Gravenstein JS. Essential Anaesthesia From Science to Practice . Cambridge, UK: Cambridge University Press 2004. </li></ul><ul><li>Hart EM, Owen H. Errors and Omissions in Anesthesia: A Pilot Study Using a Pilot's Checklist. Anesthesia and Analgesia. 2005;101:246-50. </li></ul><ul><li>Jones RW, Harrison MJ, Lowe A. Computerised anaesthesia monitoring using fuzzy trend templates. Artificial Intelligence in Medicine. 2001;21(3):247-51. </li></ul>
  23. 23. References <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Smith AF. In Search of Excellence in Anesthesiology. Anesthesiology. 2009;110(1):4-5. </li></ul><ul><li>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. </li></ul><ul><li>Vitez TS, Macario A. Setting Performance Standards for an Anaesthesia Department. Journal of Clinical Anaesthesia. 1998;10:166-75. </li></ul><ul><li>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. </li></ul>
  24. 24. Thanks to: Dave Parry and Alan Merry Staff at Advanced Clinical Skills Centre HamIT Tracient Bryan Houliston Aura Laboratory