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OBJECTIVE: This study investigates how team cognition occurs in care transitions from operating room (OR) to intensive care unit (ICU). We then seek to understand how the sociotechnical system and team cognition are related. BACKGROUND: Effective handoffs are critical to ensuring patient safety and have been the subject of many improvement efforts. However, the types of team-level cognitive processing during handoffs have not been explored, nor is it clear how the sociotechnical system shapes team cognition. METHOD: We conducted this study in an academic, Level 1 trauma center in the Midwestern United States. Twenty-eight physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) participated in semi-structured interviews. We performed qualitative content analysis and epistemic network analysis to understand the relationships between system factors, team cognition in handoffs and outcomes. RESULTS: Participants described three team cognition functions in handoffs-(1) information exchange, (2) assessment, and (3) planning and decision making; information exchange was mentioned most. Work system factors influenced team cognition. Inter-professional handoffs facilitated information exchange but included large teams with diverse backgrounds communicating, which can be inefficient. Intra-professional handoffs decreased team size and role diversity, which may simplify communication but increase information loss. Participants in inter-professional handoffs reflected on outcomes significantly more in relation to system factors and team cognition (p < 0.001), while participants in intra-professional handoffs discussed handoffs as a task. CONCLUSION: Handoffs include team cognition, which was influenced by work system design. Opportunities for handoff improvement include a flexibly standardized process and supportive tools/technologies. We recommend incorporating perspectives of the patient and family in future work.

Designing health IT aimed at supporting team-based care and improving patient safety is difficult. This requires a work system (i.e., SEIPS) evaluation of the technology by care team members. This study aimed to identify work system barriers and facilitators to the use of a team health IT that supports care transitions for pediatric trauma patients. We conducted an analysis on 36 interviews - representing 12 roles - collected from a scenario-based evaluation of T3. We identified eight dimensions with both barriers and facilitators in all five work system elements: person (experience), task (task performance, workload/efficiency), technology (usability, specific features of T3), environment (space, location), and organization (communication/coordination). Designing technology that meets every roles needs is challenging; in particular, when trade-offs need to be managed, e.g., additional workload for one role or divergent perspectives regarding specific features. Our results confirm the usefulness of a continuous work system approach to technology design and implementation.

Most surface water bodies are deteriorating, resulting in health risks and environmental damage. This study aimed to assess the performance of the modeled agri-environmental transition scenarios for restoring freshwater quality within the protection perimeter of strategic surface water drinking water catchments. Realistic agri-environmental scenarios with combined agronomic orientations were tested using a well-calibrated ecohydrological model. Their performance was quantified based on pesticide concentration reductions in freshwater bodies, focusing on temporal and spatial variability, using non-parametric tests. Our results show that it is possible to differentiate cropping mitigation scenarios according to their ability to limit pesticide transfers, taking into account the most influential biogeochemical factors in the catchment, their agronomic orientation, and their progressive implementation. Our study is also applicable to other contexts.

BackgroundThere is a growing prevalence of nonhealing wounds and chronic diseases in society, and there is an associated need for wound management solutions that include the use of telemedicine. A broad spectrum of factors influences the planning and execution of interventions within telemedicine in chronic wound management, spanning organizations, technologies, and individuals, including professionals and patients. The Telemedicine and Ambulatory Wound Care Team (TELE-AMBUS) project applies a whole-system research approach to account for this spectrum of factors. ObjectiveThe primary objective of this study was to explore and analyze the implementation and consequences of an outpatient wound management model, comprising 2 interconnected quality improvement interventions (ie, telemedicine and ambulatory wound care team) aimed at older and vulnerable patients with chronic wounds, across the specialist and primary health care sectors. Embedded in this objective is the aim to improve the competence levels of health care providers and, consequently, the service quality of outpatient wound management across specialist and primary health care services. MethodsThis project examines the implementation and consequences of an outpatient wound management model through a combined process and economic evaluation research strategy. A sociotechnical system theory approach and multiple work package design support the examination. The project uses observations, conversations, interviews, and economic assessments to gather rich, in-depth insights and understanding on why and how the new wound management model contributes to a change or not compared with the traditional treatment model. ResultsThe project has been funded from 2021 to 2025. Baseline interviews have been conducted since April 2022 and concluded in January 2024. Fieldwork, including nonparticipant observations, semistructured interviews, and informal conversations, has been conducted since November 2022 and is expected to conclude in March 2025. In parallel and as part of the cost-effectiveness analyses, time usage data on the outpatient and regular clinical models are being gathered during the fieldwork. ConclusionsWe applied a whole-system approach in multiple ways, that is, to design or inform our fieldwork and to explore, evaluate, and translate project findings into practice across services. To our knowledge, this approach has not been undertaken in telemedicine in chronic wound management literature and associated human factors and ergonomics research. Thus, our approach can produce both original and novel research and theoretical results internationally. International Registered Report Identifier (IRRID)DERR1-10.2196/55502

We need to design technologies that support the work of health care teams; designing such solutions should integrate different clinical roles. However, we know little about the actual collaboration that occurs in the design process for a team-based care solution. This study examines how multiple perspectives were managed in the design of a team health IT solution aimed at supporting clinician information needs during pediatric trauma care transitions. We focused our analysis on four co-design sessions that involved multiple clinicians caring for pediatric trauma patients. We analyzed design session transcripts using content analysis and process coding guided by Détiennes (2006) co-design framework. We expanded upon Détienne (2006) three collaborative activities to identify specific themes and processes of collaboration between care team members engaged in the design process. The themes and processes describe how team members collaborated in a team health IT design process that resulted in a highly usable technology.

BACKGROUND: As problems of acceptance, usability and workflow integration continue to emerge with health information technologies (IT), it is critical to incorporate human factors and ergonomics (HFE) methods and design principles. Human-centered design (HCD) provides an approach to integrate HFE and produce usable technologies. However, HCD has been rarely used for designing team health IT, even though team-based care is expanding. OBJECTIVE: To describe the HCD process used to develop a usable team health IT (T3 or Teamwork Transition Technology) that provides cognitive support to pediatric trauma care teams during transitions from the emergency department to the operating room and the pediatric intensive care unit. METHODS: The HCD process included seven steps in three phases of analysis, design activities and feedback. RESULTS: The HCD process involved multiple perspectives and clinical roles that were engaged in inter-related activities, leading to design requirements, i.e., goals for the technology, a set of 47 information elements, and a list of HFE design principles applied to T3. Results of the evaluation showed a high usability score for T3. CONCLUSIONS: HFE can be integrated in the HCD process through a range of methods and design principles. That design process can produce a usable technology that provides cognitive support to a large diverse team involved in pediatric trauma care transitions. Future research should continue to focus on HFE-based design of team health IT.

BACKGROUND: Clinicians need health information technology (IT) that better supports their work. Currently, most health IT is designed to support individuals; however, more and more often, clinicians work in cross-functional teams. Trauma is one of the leading preventable causes of childrens death. Trauma care by its very nature is team based but due to the emergent nature of trauma, critical clinical information is often missed in the transition of these patients from one service or unit to another. Teamwork transition technology can help support these transitions and minimize information loss while enhancing information gathering and storage. In this study, we created a large screen technology to support shared situational awareness across multiple clinical roles and departments. OBJECTIVES: This study aimed to examine if the Teamwork Transition Technology (T3) supports teams and team cognition. METHODS: We used a scenario-based mock-up methodology with 36 clinicians and staff from the different units and departments who are involved in pediatric trauma to examine T3. RESULTS: Results of the evaluation show that most participants agreed that the technology helps achieve the goals set out in the design phase. Respondents thought that T3 organizes and presents information in a different way that was helpful to them. CONCLUSION: In this study, we examined a health IT (T3) that was designed to support teams and team cognition. The results of our evaluation show that participants agreed that T3 does support them in their work and increases their situation awareness.

Orthodontic archwire materials are changing rapidly in our time. Because an ideal archwire material has not yet been found, assessment of the most effectual properties of different archwires including working range and its effect on root resorption is still an unmet clinical need. Unfortunately, most clinical studies lack standardization of subjects and force. Performing a standardized in-vivo quantitative assessment for the working range of different orthodontic archwires and its effect on root resorption was not previously attempted. This is the first study to quantitatively compare and assess these properties in a standardized split mouth design. In this work, a sample of 10 Wister rats in which one of the two upper incisors was randomly selected to receive a force of 25gram-force using CuNiTi wire while the control side received the same amount of force with NiTi. CBCT was done before and after force application to compare the working range and root resorption. The results showed a significant difference in the working range between groups favoring a larger amount of displacement in the CuNiTi(p

While there is promise for health IT, such as Clinical Decision Support (CDS), to improve patient safety and clinician efficiency, poor usability has hindered widespread use of these tools. Human Factors (HF) principles and methods remain the gold standard for health IT design; however, there is limited information on how HF methods and principles influence CDS usability “in the wild”. In this study, we explore the usability of an HF-based CDS used in the clinical environment; the CDS was designed according to a human-centered design process, which is described in Carayon et al. (2020). In this study, we interviewed 12 emergency medicine physicians, identifying 294 excerpts of barriers and facilitators of the CDS. Sixty-eight percent of excerpts related to the HF principles applied in the human-centered design of the CDS. The remaining 32% of excerpts related to 18 inductively-created categories, which highlight gaps in the CDS design process. Several barriers were related to the physical environment and organization work system elements as well as physicians’ broader workflow in the emergency department (e.g., teamwork). This study expands our understanding of the usability outcomes of HF-based CDS “in the wild”. We demonstrate the value of HF principles in the usability of CDS and identify areas for improvement to future human-centered design of CDS. The relationship between these usability outcomes and the HCD process is explored in an accompanying Part 2 manuscript.

With the growing implementation and use of health IT such as Clinical Decision Support (CDS), there is increasing attention on the potential negative impact of these technologies on patients (e.g., medication errors) and clinicians (e.g., increased workload, decreased job satisfaction, burnout). Human-Centered Design (HCD) and Human Factors (HF) principles are recommended to improve the usability of health IT and reduce its negative impact on patients and clinicians; however, challenges persist. The objective of this study is to understand how an HCD process influences the usability of health IT. We conducted a systematic retrospective analysis of the HCD process used in the design of a CDS for pulmonary embolism diagnosis in the emergency department (ED). Guided by the usability outcomes (e.g., barriers and facilitators) of the CDS use “in the wild” (see Part 1 of this research in the accompanying manuscript), we performed deductive content analysis of 17 documents (e.g., design session transcripts) produced during the HCD process. We describe if and how the design team considered the barriers and facilitators during the HCD process. We identified 7 design outcomes of the HCD process, for instance designing a workaround and making a design change to the CDS. We identify gaps in the current HCD process and demonstrate the need for a continuous health IT design process.

Emergency department (ED) disposition decision-making represents a critical juncture in patients’ care journeys, as it shapes the type of care patients access following an ED visit. However, there is a dearth of information related to how and in what context the disposition decision-making occurs. We conducted a scoping review to synthesize what previous studies reveal about the ED work system elements that influence disposition decision-making. A dual-coding screening process identified 27 articles from database searches. Articles were extracted and analyzed using the Systems Engineering Initiative for Patient Safety model. Most articles included at least two work system components. Our results suggest that the literature captures only some of the complexity of disposition decision-making, leaving certain elements underexplored or limited in scope. This review identifies informational gaps that, if addressed by future research, will support ED system redesigns that optimize patient, clinician, and organizational outcomes.

Hospital-based care of pediatric trauma patients includes transitions between units that are critical for quality of care and patient safety. Using a macroergonomics approach, we identify work system barriers and facilitators in care transitions. We interviewed eighteen healthcare professionals involved in transitions from emergency department (ED) to operating room (OR), OR to pediatric intensive care unit (PICU) and ED to PICU. We applied the Systems Engineering Initiative for Patient Safety (SEIPS) process modeling method and identified nine dimensions of barriers and facilitators - anticipation, ED decision making, interacting with family, physical environment, role ambiguity, staffing/resources, team cognition, technology and characteristic of trauma care. For example, handoffs involving all healthcare professionals in the OR to PICU transition created a shared understanding of the patient, but sometimes included distractions. Understanding barriers and facilitators can guide future improvements, e.g., designing a team display to support team cognition of healthcare professionals in the care transitions.

This article presents the conceptual framework for assessing farm sustainability using the IDEA4 method. IDEA4 combines a dual assessment approach based on sustainable agriculture objectives and the properties of sustainable farming systems. It is rooted in the domains of strong sustainability, strong agroecology and the multifunctionality of agriculture. It takes into account the overall issues of sustainable agriculture. This conceptual framework has been used to construct 53 indicators for analysing farm sustainability using two complementary approaches. The first assesses sustainability by organising these 53 indicators according to the 3 normative dimensions of sustainable development (agroecological, socio-territorial, economic), structured into 13 components. This assessment relies on a scoring system based on 100 sustainability units for each of the 3 dimensions, which cannot offset each other. The second approach is used to assess sustainability by organising the same 53 indicators according to the 5 properties of sustainable agricultural systems (ability to produce and reproduce goods and services, autonomy, robustness, territorial embeddedness, and overall responsibility), which are arranged in a tree structure with 15 branches. Indicators are aggregated in a qualitative and hierarchical manner using the DEXi tool. The exploratory potential of the concept of the properties of sustainable systems encourages a transdisciplinary approach for assessing farms. IDEA4’s theoretical framework is now complemented by three information technology (IT) tools, which means that the method can be used to a much greater extent to support the agroecological transition.

Pediatric trauma is one of the leading causes of morbidity and mortality in children in the USA. Every year, nearly 10 million children are evaluated in emergency departments (EDs) for traumatic injuries, resulting in 250,000 hospital admissions and 10,000 deaths. Pediatric trauma care in hospitals is distributed across time and space, and particularly complex with involvement of large and fluid care teams. Several clinical teams (including emergency medicine, surgery, anesthesiology, and pediatric critical care) converge to help support trauma care in the ED; this co-location in the ED can help to support communication, coordination and cooperation of team members. The most severe trauma cases often need surgery in the operating room (OR) and are admitted to the pediatric intensive care unit (PICU). These care transitions in pediatric trauma can result in loss of information or transfer of incorrect information, which can negatively affect the care a child will receive. In this study, we interviewed 18 clinicians about communication and coordination during pediatric trauma care transitions between the ED, OR and PICU. After the interview was completed, we surveyed them about patient safety during these transitions. Results of our study show that, despite the fact that the many services and units involved in pediatric trauma cooperate well together during trauma cases, important patient care information is often lost when transitioning patients between units. To safely manage the transition of this fragile and complex population, we need to find ways to better manage the information flow during these transitions by, for instance, providing technological support to ensure shared mental models.

Trauma is the leading cause of disability and death in children and young adults in the US. While much is known about the medical aspects of inpatient pediatric trauma care, not much is known about the processes and roles involved in in-hospital care. Using human factors engineering (HFE) methods, we combine interview, archival document and trauma registry data to describe how intra-hospital care transitions affect process and team complexity. Specifically, we identify the 53 roles directly involved in patient care in each hospital unit and describe the 3324 total transitions between hospital units and the 69 unique pathways, from arrival to discharge, experienced by pediatric trauma patients. We continue the argument to shift from eliminating complexity to coping with it and propose supporting three levels of awareness to enhance the resilience and adaptation necessary for patient safety in health care, i.e. safety in complex systems. We discuss three levels of awareness (individual, team and organizational) and describe challenges and potential sociotechnical solutions for each. For example, one challenge to individual awareness is high time pressure. A potential solution is clinical decision support of information perception, integration and decision making. A challenge to team awareness is inadequate non-technical skills, e.g., leadership, communication, role clarity; simulation or another form of training could improve these. The complex, distributed nature of this process is a challenge to organizational awareness; a potential solution is to develop awareness of the process and the roles and interdependencies within it, by using process modeling or simulation.

OBJECTIVE: To describe physician perceptions of the potential goals, characteristics, and content of the electronic problem list (PL) in pediatric trauma. METHODS: We conducted 12 semistructured interviews with physicians involved in the pediatric trauma care process, including residents, fellows, and attendings from four services: emergency medicine, surgery, anesthesia, and pediatric critical care. Using qualitative content analysis, we identified PL goals, characteristics, and patient-related information from these interviews and the hospitals PL etiquette document of guideline. RESULTS: We identified five goals of the PL (to document the patients problems, to make sense of the patients problems, to make decisions about the care plan, to know who is involved in the patients care, and to communicate with others), seven characteristics of the PL (completeness, efficiency, accessibility, multiple users, organized, created before arrival, and representing uncertainty), and 22 patient-related information elements (e.g., injuries, vitals). Physicians suggested criteria for a PL varied across services with respect to goals, characteristics, and patient-related information. CONCLUSION: Physicians involved in pediatric trauma care described the electronic PL as ideally more than a list of a patients medical diagnoses and injuries. The information elements mentioned are typically found in other parts of the patients electronic record besides the PL, such as past medical history and labs. Future work is needed to evaluate the optimal design of the PL so that users with emergent cases, such as pediatric trauma, have access to key information related to the patients immediate problems.