Aspects of the Proposed Work Problem solvingInteraction designSoftware engineering.

Aspects of the Proposed Work

KeyChecker

checkKey() : boolean

KeyChecker

checkKey() : boolean

Key

code_ : long

getCode() : long

Key

code_ : long

getCode() : long

LightCtrl

lit_ : boolean

getLit() : booleansetLit(v : boolean)

LightCtrl

lit_ : boolean

getLit() : booleansetLit(v : boolean)

KeyStorage

getNext() : Key

KeyStorage

getNext() : Key

PhotoSObsrv

isDaylight() : boolean

PhotoSObsrv

isDaylight() : boolean

Logger

logTransaction(k : Key)

Logger

logTransaction(k : Key)

Controller

numOfTrials_ : longmaxNumOfTrials_ : long

enterKey(k : Key)

Controller

numOfTrials_ : longmaxNumOfTrials_ : long

enterKey(k : Key)

1

1

1

1

1

sensor

lightCtrl

1 checker

alarmCtrl

lockCtrl

logger

11..*

validKeys 1

AlarmCtrl

soundAlarm()

AlarmCtrl

soundAlarm()

LockCtrl

open_ : boolean

getOpen() : booleansetOpen(v : boolean)

LockCtrl

open_ : boolean

getOpen() : booleansetOpen(v : boolean)

Problem solving Interaction design Software engineering

Intensive care unit (ICU)

CT scan

Resuscitation bay Operating room (OR)

Level-1Trauma CenterPatient

Local Hospital

Patient’s Hospitalization Path

?

?

Ambulance

?

?

Nurse recorder (REC)Scribe; records patient data, results of tests & treatments on flow sheet. Coordinates nursing care

Monitor for viewing X-rays

Attending physician (ATP)Supervises the trauma team; interfaces with major decision making

Glass-enclosed supply cabinet

EMS paramedicBriefs the team, then the scribe, about the trauma incident

Vital signs monitor:1) Blood pressure; ECG2) Pulse oximetry: heart rate + oxygen saturation (SpO2)3) Respiratory rate

Anesthesiologist (ANST)Assists with airway management; performs intubation

Critical care technician (CCT) Orderly; obtains & sets up equipment; assists with procedures; takes vital signs

Team leader (TL)(Senior resident)Directs resuscitation; delegates work to others

Doer physician (JR)(Junior resident)Performs tasks assigned by team leader

Trauma flow sheet

Refrigerator for medications & blood

Physician recorder(student) Informally records patient data & treatments for physician’s post-event review

Primary nurse (PNR)Coordinates bedside nursing care; assists with all procedures; stays with the patient until leaves ED

Respiratory therapist (RT)Sets up ventilator; assists with intubation

Orthopedic resident (ORT)Assesses and treats fractures

HR

SpO2

ABP

PAP

CO2

11094

10732.137.25.62134

96/56(69)

25/10(15)

RR

C.O.

Tblood

Tperi

PulseHR

SpO2

ABP

PAP

CO2

11094

10732.137.25.62134

96/56(69)

25/10(15)

RR

C.O.

Tblood

Tperi

Pulse

Tablet PC docked,with Bluetooth base station,Wi-Fi Internet access,Speech recognition engine

RFID tag reader

Main computerwith Bluetooth BS,Wi-Fi Internet access,Speech reco engine

RFID tag readers

Bluetooth headsets with close-talking microphone

Wall displays

Video cameras

Room speakers

Tablet PCs or PDAs,with Bluetooth base station,Wi-Fi Internet access,Speech recognition engine

Directional overhead microphones


Attending physician (ATP)Supervises the trauma team; interfaces with major decision making


Primary nurse (PNR)Coordinates nursing activities; assists with all procedures; stays with the patient until discharged



Team leader (TL)Senior resident; decision maker; delegates work to others

Work benchOxygen outlet

Nurse recorder (REC)Scribe; records patient data, results of tests & treatments on TAFS. Uses default charting: records only exceptions

Trauma Assessment Flow Sheet (TAFS)

Critical care technician(CCT) Orderly; obtains & sets up equipment; assists with procedures; takes vital signs

Doer doctor (JR)Junior resident;performs assignments by Team leader


Cardiac arrest cart

Code cart with emergency resuscitation medications and supplies

Refrigerator for blood & medications

Typical room dimensions: 8 5 meters

Chief resident (CHF)Assumes the leadership role, if present.

Team leader (TL)(Senior resident) Directs resuscitation; delegates work to others

Work benchOxygen outlet

Nurse recorder (REC)Scribe; records patient data, results of tests & treatments on flow sheet. Coordinates nursing care

Trauma assessment flow sheet

Critical care technician(CCT) Orderly; obtains & sets up equipment; assists with procedures; takes vital signs

Doer doctor (JR)(Junior resident) Performs tasks assigned by team leader


Cardiac arrest cart

Code cart with emergency resuscitation medications and supplies

Refrigerator for medications & blood



Attending physician (ATP)Highly experienced surgeon; Supervises resuscitation; interfaces with major decision making


Primary nurse (PNR)Coordinates bedside nursing care; assists with all procedures; stays with the patient until leaves ED



Chief resident (CHF)More senior than TL; Not assigned a specific role but, if present, often assumes the leadership role.

Team leader

Nurse recorder

Critical care technician

Doer doctor

Respiratory therapist


Attendingphysician

Orthopedic resident

Primary nurse

Chief resident

1. EMS reporting to the trauma team

2. EMS reporting to the nurse recorder

Information Flows

Nurse recorderTAFS

Team leaderTrauma team / Providers

Info

rma

tion

so

urc

es

Physician recorderPhysician’sdescriptive

record

Signed-offphysician’s

record

VisualVerbal

Handwriting

Handwriting Handwriting

Visual

Visual

Verbal

Wall charts, Broselow tape

EMS staff report ()

Vital signs monitor

Patient assessment (†)

Equipment, medications

Lab tests (‡)

Applied tests and treatments

X-ray images (§)

CT scans (@)

Information Flows

Nurse recorder

TAFS(Trauma Assessment Flow Sheet)

Team leaderTrauma team (Care providers)

Info

rma

tion

so

urc

es

Physician recorderPhysician’sdescriptive

record


record

Verbal

Handwriting


Verbal

Wall charts, Broselow tape

EMS staff report

Vital signs monitor

Patient assessment

Equipment, medications

Lab tests ()

Applied tests and treatments

X-ray images (†)

CT scans (‡)

Visual,Verbal,Paper

Prehospital

Intake

Airway

Breathing

Circulation

Disability

Oxygenation, etc.

System Sequence Diagrams

telephone call

EMS paramedic«primary actor»

answer

prompt for patient status during transport

Telephone operator«offstage actor»

EMS dispatcher«supporting actor»

Nurse recorder«offstage actor»

quadruple: age, code, transportation-means, estimated-arrival-time

pass on the EMS quadruple

patient status during transport

pass on the patient status during transport

Time

Team Configuration @ UPenn

RecorderCommandPhysician

TraumaNurse

AssistantSurgeon

Anesthesiologist (2)

RespiratoryTechnician

PrimaryResuscitator

X-rayTechnician (2)

LaboratoryTechnician

Team Configuration @ Liverpool

ScribeNurse

TeamLeader

CirculationNurse

OrthopedicRegistrar

Airway Doctor

AirwayNurse

CirculationDoctor

Wardsperson

SocialWorker

Team Config. @ UMDNJ RWJ-H

RecordingNurse (REC)

CriticalCareTechnician (CCT)

PrimaryNurse

(PNR)

OrthopedicResident

(ORT)

JuniorResidentFellow (JR)

AttendingPhysician

(ATP)

Trauma flowsheet (TAFS)

Vital signsmonitor

RespiratoryTechnician (RT)

Team Leader(TL)


Wide-angle, ceiling-mounted cameraslanted to provide entire-room view

Ceiling-mountedmicrophone

Recordingnurse

Ceiling-mountedmicrophone

Ceiling-mounted camerafacing down to provideview around the head of the bed

Doorway

Audio Communication System

Walldisplay

Host tablet PCwith Bluetooth base station,Wi-Fi Internet access,Speech recognition engine

Bluetoothheadset

Marker fortracking

Scribe

ControlsFile Edit View Tools Configure Help

12,082

Total Budget

2,500

This Session Max

CloseApply

Information Preferences

Text VideoAudio

P11 P5 P3Display


12,082

Total Budget

2,500

This Session Max

CloseApply


Text VideoAudio

P11P11 P5P5 P3P3Display

Close-talkingmicrophone

Audio Communication System (2

Tablet PCwith Bluetooth base station,Wi-Fi Internet access,Speech recognition engine

Bluetoothheadset

Virtual marker for tracking(individualized)

Scribe


12,082

Total Budget

2,500

This Session Max

CloseApply


Text VideoAudio

P11 P5 P3Display


12,082

Total Budget

2,500

This Session Max

CloseApply


Text VideoAudio

P11P11 P5P5 P3P3Display

Close-talkingmicrophone

Maincomputerwith Bluetooth BS,Wi-Fi Internet access,Speech reco engine

Ulnarartery

Brachialartery

Aorta

Poplitealartery

Carotidartery

Subclavianartery

Radialartery

Femoralartery

Brachialvein

Superiorvena cava

Inferiorvena cava

External /Internaljugular vein

Femoralvein

Poplitealvein

Thoracicaorta

Heart

Circulation

Disability & Exposure (not shown)

Rightlung

Leftlung

Trachea

Rightbronchus

Diaphragm

CarinaRibs

Pleura

Pleural cavity(Intrapleural space)

Breathing

Leftbronchus

Heart

TracheaTongue

Esophagus

Airway

Epiglottis

LarynxNasalcavity

Cricoid

Oropharynx

1015

203040

Dry Suction Control

PLEUR-EVAC

1015

203040

Dry Suction Control

1015

203040

Dry Suction Control

PLEUR-EVAC

Foleycatheter

Pulseoximeter

Pleuralchest tube

ECGelectrodes

Nasogastral(NG) tube

Endotracheal(ET) tube

Intravenous (IV) bagIV accesscannula

Femoralcordis

Vital signs monitor

Pleur-evacchest

drainage equipment

Stethoscope

Blood pressuremonitor

Bag valve mask (BVM)

Focused abdominal sonogram for trauma

(FAST)

Intraosseousinfusion (used in children)

HR

SpO2

ABP

PAP

CO2

11094

10732.137.25.62134

96/56(69)

25/10(15)

RR

C.O.

Tblood

Tperi

PulseHR

SpO2

ABP

PAP

CO2

11094

10732.137.25.62134

96/56(69)

25/10(15)

RR

C.O.

Tblood

Tperi

Pulse

Rapid flow fluid warmer and infuser

HR

SpO2

ABP

PAP

CO2

11094

10732.137.25.62134

96/56(69)

25/10(15)

RR

C.O.

Tblood

Tperi

Pulse

Information Flows

Nurse recorder

TAFS(Trauma Assessment Flow Sheet)

Trauma team

So

urc

es

of

pa

tien

t in

form

atio

n

Physician recorder Physician’snotes


record

Handwriting


VerbalAdministered medications

EMS staff report (verbal)

Vital sign instruments

Patient assessment:Look-listen-feel, auscultation, urine output, peritoneal lavage

Fluid/blood infusers

Equipment:Ultrasound, ventilator, pleur-evac chest drainage

Therapeutic treatments:Bleeding control, orthopedic interventions

Blood/urine lab tests ()

X-ray images ()

Patientrecord

Verbal

Information source Channel Receiver Records

Visual / Verbal

Verbal

(often not communicated)

Verbal

Verbal

Visual / Verbal

Verbal

(often not communicated)

Paper

Visual / Verbal

Goals, Tasks, Procedures

Goals (“what”)

Tasks (“how”)

Procedures (detail “how”)

System

State variables

Actors(Trauma team)

System(Patient)

var1

var2

varn

Currentstate

Desiredstate(goal)

Systemstate space

Interventions

Incr

easi

ngle

vel o

fab

stra

ctio

n

(a)

(b)

ChecklistMechanism of Injury

Fall from a height ( 5m) Explosion Jammed in a car Ejection from the car Death of another passenger Pedestrian or cyclist hit by a car High-speed car or motorcycle collision

ChecklistVital Signs

Glasgow-Coma Score 10 Blood pressure 80 mmHg Respiratory rate 10 or 29 SpO2 90 % (RA)

ChecklistType of Injury

Flail chest Open thorax Unstable pelvic fracture Fractures of 1 long bone or the lower extremity Major amputations Multiple rib fractures plus concomitant injuries

correction

surgicalcricothyrotomie

intubate

compression

pulsless?

arterialbleeding?

RR 10/min?

airwaysobstructed?

intubated?malposition of

endotrach. tube?

laryngoscopypossible?

A

B

Cconsider CPR?

suspected severe ormultiple injuries 1

no

no

no

no

no

yes

yes

yes

yes

yes

yes

no

no

yes

Two Problems Solved

TRAUMA BAY

STABLEor

UNSTABLE?

Primary survey

DETERMINE ALLINJURIES OR

POTENTIAL INJURIES

Secondary survey

initial decision revised decisionICU

Injury that requires monitoring or treatment that cannot be accomplished on

the floor

Operating roomInjury if not operated on immediately will lead to morbidity or mortality

FloorInjury that needs monitoring or treatment that cannot be

done at home

HomeNo injury requiring monitoring

or treatment

unstable

Goals and Tasks (1)

Mouth, nose, and neck sight

Level of consciousness and talk

State variables

Chest sight (wounds, bruises?)

Skin color and temperature

External bleeding presence

Systolic/diastolic blood pressure

Heart rate / Pulse

Urine output

Body temperature

Blood cellular composition

Abdominal sonogram

Stabilize spinal cord

Tasks (Intervention)

Oxygenate via face mask

Establish two IV accesses

Breath sounds (noise)

Breath sounds (lateral symmetry)

Peripheral oxygen saturation (SpO2)

CO2 level in exhaled gas

Respiratory rate (RR)

Chest movement normalcy (flail?)Maintain perfusion

Free airway

Stable circulation

Identify and treat injuries

Devise definitive care plan

Goal hierarchy of resuscitation

Functional breathing

( Immediate threat to life )

( Potential threat to life )

Mouth AND/OR nose open

Oropharynx unobstructed (e.g. tongue)

Larynx unobstructed (e.g. epiglottis)

Trachea free

Adequate ventilation

Overt bleeding controlled

Functional gas exchange

Pneumo/hemo-thorax excluded or treated

Cardiac output normal

Internal bleeding excluded or controlled

Hemoglobin concentration > 10 g/dl

Open wounds dressed

Blood fluid balance

Patient’s body temperature normal

Draw blood for analysis

Setup vital sign monitoring

Tasks (Observation)Receive EMS report

Goals and Tasks (2)

Indicated tasksExample observations(result of Observation tasks)

No visible injuries to face&neck

?Lucid talking

?

Setup oxygen saturation monitor

?

?

Inte

rve

ntio

nta

sks

Ob

serv

atio

nta

sks

Observation tasks

Get the patient to talk

Oxygenate via face maskVisually inspect face/neck area

Listen for noise in breathing

Alternative Perspective: Goals

ICU

OR

Hospitalfloor

Home

Badoutcome

Stablefor CT

Unstablefor CT

Patient

Go directlyto OR

Stable forultrasound/DPL

Computerized Decision Support

Research Approach

Bottom-upEthnographic data collection, video tagging and analysis

Top-downCognitive work analysis of goals and ATLS protocol

Workload, team structure, critical decisions and

associated input parameters

Goals and subgoals, critical decisions and associated

input parameters

Augmenting Team Communication and

Information Presentation

Monitoring Team Activities and Alerting

about Errors and Inefficiencies

1.

2.

Control Tasks (1)

Observe

Goal

modalitymultiplicity

Channel

Sender Receiver

Communication

Decide Intervene

Short-term memory: Situation information

Long-term memory: Knowledge

Long-term memory: Knowledge

Control Tasks (2)

Sharedgoals

Team

Observe Communicate Decide Communicate Intervene

Short-term memory: Situation information

shortcut

Control Tasks – Example

Observevar 1

Observevar 3

var1

var2

var3

Actualcurrentstate Goal

state

Observedcurrentstate

var1

var2

var3

Actualcurrentstate Goal

state

Observedcurrentstate

DecideIntervene

int 1

var1

var2

var3

Actualcurrentstate

GoalstateObserved

currentstate

Achievedstate

int1

STEP 1 STEP 2 STEP 3 STEP 4

var1 = blood pressurevar2 = oxygen saturationvar3 = heart rate int1 = crystalloid infusion

diagnosehypovolemia increaseblood volumevar1:

var3:

Cognition Model

Sensing Motor Behavior

Predictionmodule

Predictionmodule

Predictionmodule

Predictionmodule

Cognitiveprocessing

Attentionsearchlight

Sensing Motor BehaviorSensing Motor Behavior

Predictionmodule

Predictionmodule

Association

Index ofpredictedscript

Prediction moduleIN

Long-termmemory

Workingscript

OUT


IN

OUT

Reportmismatch

• Ignore/rationalize

• Repair by alternative script

• Report mismatch

Models Relationship

Infrastructure plane of psychological processes

Problem plane of problem-specific tasks(“Workflow”)

do X

do Y

prob D1

Goodoutcome

Bad

G

B

Pr(diagnosis)

Util

ity

Test utility

Utilityof X

Utilityof X

Threshold

Pr(D1)

DECISION:Do test

(a) (b)

Currentdiagnosis

Threshold Don’t test(unnecessary)

0 1

Pr(diag)Test

Threshold0 1

Pr(diag)

Successive pieces of evidence

Threshold 0

4

18

(a)

(b)

(c)

lnFN

TN

Task Allocation

Pending tasks: T1, T2Qualified tasks:1. T2

Pending tasks: T1, T2, T7Qualified tasks:1. T1

(prioritized)

2. T7

Team member, Pi Team member, Pj

Pending tasks: T1, T2, T5Task allocation: T1 Pk T2 Pi T5 Pj

Team leader, Pk

Given a currentset of sharedgoals:

Abstract Model of Teamwork

O1

O2

OM

I1

I2

IN

D2

D1 D3

DK

Decision j

Oi

Ik

Observation i

Intervention k

Dj

Comm. Link

Scenario 1: IV Bag Low

IV bag IV bag

Primarynurse

Scribe

S1

A1

CCT

Other teammembers

decide to ignore

broadcast

D1

Comm.O ID O ID O IDComm.Comm.O D IComm. vs.

Technician Physician Nurse Technician Physician Nurse

Model Simulation

Abstract ModelSimulator

Input:patient scenario

Output:simulation trace

StatisticalAnalysis

Output:identified teamworkProblems/errors

Actors(Trauma team)

System(Patient)

Researchers(Our team)

System(Trauma bay) System state variables:

• aspects of task management awareness start time execution duration performance quality loss

• degree of leadership

• communication intensity

Tasks Level

Procedural and Communication Level

Goals Level

Visual Displays

Wall display

Main computer

Tablet PC 1

Tablet PC 2

Nurse recorder

Physician recorder

From vital sign instrumentsand RFID tag readers

Drop-downdisplay

To othercomputers

(b)(a)

Use

r in

terf

ace

(Dat

a en

try

& v

isua

lizat

ion)

Visualization rules & constraints

Trauma protocol(ATLS etc.)

Object tracking(RFID, vision)

Signal processing& data analysis

Patient data repository

Co

llab

ora

tive

m

idd

lew

are

Admin user interface(for modifying rules &

constraints of the protocol, visualization, and alerting)

Shared state

User

Wall display

Main computer

Tablet PC 1

Tablet PC 2

Nurse recorder

Physician recorder

From vital sign instrumentsand RFID tag readers

Drop-downdisplay

Pending Tasks Display

Mouth / airwayMouth / airwaycompromisedcompromised

SpO2 = 60 %SpO2 = 60 %

Airway

Breathing

Disab

ility

Circulation

Abstract Model (1)

Channel

modalityn-arity

Sharedgoals

Channel

Sender Receiver

DecisionS Sensing D A ActionCommunication

DecisionSensing Action

Goal

LTM: knowledge

STM: situation

S AD S AD S AD

Abstract Model

ReceiverSender Channel

S1

S2

SM

A1

A2

AN

D2

D1 D3

DK

Communication

DecisionSensing Action

Communication CommunicationSensing ActionDecision

Decision j

Si

Ak

Sensing i

Action k

Dj

Comm. Link

Goal

S AD

Sharedgoals

S AD

Abstract Model (2)

S1P1

S2

SM

PK

A1

A2

AN

ProcessorPj

Si

Ak

Sensor

Actuator

RelayRm

R1

R2

Goals and Tasks (1)

Inspect mouth and airway

Measure respiratory rate

Measure blood oxygenation

Measure CO2 level

Tasks (Sensing)

Maintain perfusion

Airway patency

Circulation stability

Identify and treat injuries

Devise definitive care plan

Goals of resuscitation

Mouth open OR nose open

Tongue not obstructing airway

Trachea free

Respiratory rate > 10 and < 29/min

Bilateral breath sounds

Heart rate normal (?)

Hemoglobin count normal (?)

Blood pressure > 80 mmHg

Blood oxygenation (SpO2) > 90 %

External bleeding treated

Breathing normalcy

( Immediate threat to life )

( Potential threat to life )

Listen for noisy breathing

Check if patient is agitated

Inspect cervical spine

Check if patient can talk lucidly

Measure respiratory rate

Measure blood oxygenation

Do chest auscultation

Inspect for external bleeding

Inspect for thoracic bruises

Draw blood for tests/HemoCue

Measure patient’s temperature

FAST detect abdomen bleeding

Foley catheter for urine output

EMS report

Input information Put oxygen mask

Establish IV access

?

Tasks (Action/Intervention)

Goals and Tasks (4)

Maintain perfusion Breathing normalcy

Airway patency

Circulation stability

Identify injuries

Devise long-term care

GoalsCan patient talk lucidly ?

Mouth and airway unobstructed ?

Noisy breathing ?

Agitated?

Respiratory rate < 10 or > 29/min ?

Blood oxygenation (SpO2) < 90 % ?

Tasks (Sensing)

Blood pressure < 80 mmHg ?

Heart rate ?

Hypoveolemnia (blood loss) ?

Open thorax ?

Flail chest ?

Cervical spine injuries ?

Penetrating injuries ?

Pelvic injuries ?

Mouth and airway

Mouth and airway

uncompromised

uncompromised

SpO2 > 90 %

SpO2 > 90 %

Abstract Model (2)

Perception Behavior

OUT

IN

IN

OUT

Long-termmemory


Workingscript

Comparator

Report ifmismatch

Hierarchylayer i

Cognitiveprocessing

Aspects of the Proposed Work Problem solvingInteraction designSoftware engineering.

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Transcript of Aspects of the Proposed Work Problem solvingInteraction designSoftware engineering.