Iterative design of a real-time information display for a fastpaced, high-risk medical setting
Nicole
1
Ferraro ,
Aleksandra Sarcevic,
2
PhD ,
Dr. Sage R. Myers,
3
MD
1. Drexel University School of Biomedical Engineering, Science and Health Systems, 2. Drexel University College of Computing and Informatics, 3. Children’s Hospital of Philadelphia
Discussion
Results
Introduction
Overall, positive feedback was received regarding the second iteration of the proposed design for an information
display in the trauma setting. All of the design criteria, represented by the statements posed to different trauma team
members during evaluation sessions, received ratings above the neutral point of 3.5, indicating that the criteria are
being met and the trauma team agrees that there is a clinical need for such a tool in this environment. This usercentered, iterative design approach allows for feedback at every step of the design process to ensure that the tool is
meeting the needs of the users and the environment, which was demonstrated by several comments and rankings. For
the third design iteration, the criteria involving timing and type of information were particularly considered, as they
received the lowest scores from the participating users. The information presented was minimized to contain only the
most crucial and time-sensitive information.
Traumatic injuries are a leading cause of death and disability in both children and young adult populations. During initial
management of a critically injured patient, called trauma resuscitation, the trauma team stabilizes the patient, determines
the injury extent, and develops an initial treatment plan. This process is error-prone because providers are managing
patients with unstable and unpredictable medical states while making time-critical decisions without the advantage of a
detailed medical history. There have been efforts to develop information systems to support trauma teams during
resuscitations, but with limited success. Developing information tools to support trauma teamwork requires collaboration
with trauma team members to ensure that the tools support the needs and requirements of this complex environment. We
have used participatory design workshops and simulation sessions with trauma teams to understand how they interact
with potential supplementary information technologies during resuscitations. Based on these data, we proposed a
preliminary design of an information display that would increase situation awareness and information sharing during the
resuscitation process. To design such a display, we worked with the Level 1 trauma center at the Children’s Hospital of
Philadelphia.
Methods
A combination of participatory design workshops, simulations and heuristic evaluation sessions was used to create the
designs for an information display to improve situation awareness during resuscitations. We conducted two participatory
design workshops, each with 5-7 trauma team members to understand their information needs and work challenges.
Based on this feedback, we created an early display prototype that was then evaluated in three simulation sessions.
During each simulation, trauma team members responded to a patient scenario using a patient mannequin. We displayed
our early design prototype using a portable monitor. A researcher was entering patient and process information for the
display on a specially designed user interface, simulating the real functioning of the display. After teams completed the
patient scenario, we conducted a group discussion, inquiring about the display usefulness and usability. Using this
feedback, we revised the display design, producing its second iteration . This second display design was then evaluated
using heuristic evaluation (HE). No need to describe this theory behind three types of user involvement; methods should
focus on your study protocol and what we did. Participants were also asked if they felt the present design would be useful
to their role in the resuscitation, and if they foresaw any issues or concerns with incorporating such a display into their
work environment. By incorporating end users into the design process, we believe the end product will be sufficient not
only for the original purpose of the design, but also for the environment in which it will be used.
Conclusion
The first iteration of the information display design was created based on data collected though the participatory design workshops, and was then
evaluated during simulation sessions with trauma teams. Participants’ comments were incorporated into the second iteration of the display. The
second design iteration (see above left) attempts to improve the layout of the design for easy interpretation and separation of different types of
information. This design was tested in one-on-one heuristic evaluation sessions, with each trauma team role represented. The average rankings
for each survey question is shown in the table below. These rankings, in addition to the specific comments provided by the participants during
the sessions, were used to create the third iteration of the design (see below). The rankings were used to provide an overview of how the display
performed in each category, but the comments about each section were most beneficial during the design refinement process. Display section that
received the most comments includes the timing system and whether it refers to time relative to patient arrival or absolute time, based on the
clock. Other common comments included the use of color on the display, In the case of vitals, participants commented that the green and red
colors were confusing and had no meaning, explaining how green and red are often used to indicate normal or abnormal.
The third and current iteration of the design is the product of
feedback received during the heuristic evaluation sessions
(see left). This design takes into account the meaning that
colors may convey in interpretation, as well as the need for
treatments listed both cumulatively and as individual doses.
Some terminology was changed, such as specifying that
blood pressure is the mean arterial pressure, and the blood
gas order now corresponds to the way the results are returned
from the labs. The feedback consensus was to use elapsed
time since patient arrival and to specify that in the labeling,
as well as to add a timestamp to the GCS, or Glasgow-Coma
Scale, value. Participants also felt that only abnormal findings
need to be reported, as those are the facts that will play a role
in the treatment decision-making process. Finally, since lab
results, other than blood gasses, are not usually returned
during the time that the patient is still present in the bay, that
section was removed from the design.
•
•
•
•
•
•
•
•
Display presents useful information
The information presented on the display is sufficient
The display, including symbols and icons, is easy to understand and interpret
The design is clear, visible, and readable, in regards to colors and sizing of the components
The terminology used on the display is consistent with terms used in the trauma bay
The display is an improvement over current information sources in the trauma bay
The design layout is easy to follow and makes sense as presented
The timing for medications and vitals is easy to interpret and is presented as it is recorded in the trauma bay (elapsed
time vs. absolute time)
•  This tool will help improve coordination among different team members
•  This tool will assist in physician decision-making
•  This tool will help minimize memory load for team members
Statement
Ranking (1-7)
Display presents useful information
6.25
The information presented on the display is sufficient
5.875
The display, including symbols and icons, is easy to understand and interpret
6.125
The design is clear, visible, and readable, in regards to colors and sizing of the components
6.5
The terminology used on the display is consistent with terms used in the trauma bay
6.5
The display is an improvement over current information sources in the trauma bay
7
The design layout is easy to follow and makes sense as presented
6.25
The timing for medications and vitals is easy to interpret and is presented as it is recorded in the trauma bay
5.57*
This tool will help improve coordination among different team members
6.14*
This tool will assist in physician decision-making
6.375
This tool will help minimize memory load for team members
6.875
*Eight total interviews were conducted, each lasting about 60 minutes, and each member of a typical trauma team was represented. In two
incidences, those interviewed did not provide a definite ranking, and so the average was determined from the seven rankings that were provided.
The above images represent the three methods used to obtain feedback on the design iterations. To the top right, results from a
participatory design session, in which members of the trauma team came together to discuss what information would be best included
on the display. The bottom left shows the display on the screen during a simulation session used to determine how the display could be
used in the resuscitation setting. To the right, a trauma team member participates in a heuristic evaluation setting, where trauma team
members participate in one on one interviews to evaluate the components of the display design.
To the right are examples of display feedback
received during the heuristic evaluation sessions
used to evaluate the second design iteration and
create the current design. Check marks indicate
positive components of the design while x marks
indicate areas of the design that need improvement
or are unnecessary to include. The two displays
shown here are from interviews with a medication
nurse and an attending trauma surgeon.
The most important design criteria for the information display, in terms of fulfilling an unmet clinical need, is
represented by the statement asking participants to rank whether the display is an improvement over current
information sources in the trauma bay. That statement was given a perfect rank of seven by every member of the
trauma team in our sessions. Current information sharing practices in the fast-paced setting of a trauma center are not
sufficient to allow team members to access information quickly. The criteria that the display reduces memory load for
team members received a near-perfect ranking, indicating that this display has potential to greatly improve current
trauma bay practices and reduce the stress of tracking down patient information.
Future Work
The latest iteration of the information display design has not yet
been reviewed by the trauma team, and so future work centers
around obtaining feedback, both through sessions as well as in a
simulation setting, regarding the feasibility and effectiveness of
the current design. For simulation use, the design will be
implemented so that it can be displayed on screens during the
simulation and updated in real time. Currently, it is updated
through a dedicated data entry team member, but in the future,
the hope is that much of this data can be automatically fed into
the display. This can be made possible by utilizing already
existing technologies in the trauma bay, such as vital signs
monitors, as well as through the development of new
technologies, such as a flow monitor to determine medication
doses and frequency as they enter the patient, and the use of
RFID tags to identify medications. Overall, the iterative design
process will continue with the goal of eventually using the
display in the trauma bay during resuscitation events, with the
information updated automatically in real-time using the
existing methods in the trauma bay, as well as through new
implementations of data collection.
Further simulations will be conducted with the
latest design implemented to understand how the
team relates to the display
References
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Sarcevic, A., & Burd, R. S. (2008). “What’s the Story?” Information Needs of Trauma Teams. In AMIA Annual
Symposium Proceedings (Vol. 2008, p. 641). American Medical Informatics Association.
Scariot, C. A., Heemann, A., & Padovani, S. (2012). Understanding the collaborative-participatory design. Work: A
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Hardstone, G., Hartswood, M., Procter, R., Slack, R., Voss, A., and Rees, G. Supporting informality: Team working
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Acknowledgements
The authors would like to acknowledge the Emergency Department at the Children’s Hospital of Philadelphia for their enthusiastic participation
in evaluating the information display designs and for allowing us to use simulation training for gathering additional information regarding how
the team interacts with the display. We also acknowledge our funding source, National Science Foundation, grant # IIS-1253285
.