E110 Chris Hicks and Andrew Petrosoniak on Human-Centred Design in the Emergency Department
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Chad Ball 00:12
Welcome to the Cold Steel podcast hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only master classes on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as a surgeon, and perhaps more importantly, as a human.
Ameer Farooq 00:42
We've all experienced the frustration of working in clinical environments that just don't seem to be set up intuitively. But what if there were ways to improve the design of the places and the processes in which clinicians practice? In this episode, we spoke with Dr. Andrew Petrosoniak and Dr. Chris Hicks, both emerge docs at St Mike's Hospital in downtown Toronto. They have done extensive work on human centered design in healthcare and have done amazing work redesigning the St. Mike's trauma bay, and many other areas in the St. Mike's Emergency Department, check out the links in the show notes to see the pictures of their newly redesigned trauma bay. And also, check out their website, advancedperformance.ca.
Chad Ball 01:33
I was wondering if you could tell some of our listeners who may not know you as well as we do, where you each grew up and what your training pathway was to where you are? And maybe we'll start with you, Andrew.
Andrew Petrosoniak 01:41
Okay, great. I work at St. Mike's. I'm an emerge doc and a trauma doc at St Mike's hospital. I've been there for about seven years now. I grew up in Ontario, small town, Lindsay and made my way through to med school in Ottawa, and then residency in Toronto. I have since settled down here. So, I spend most of my time thinking about trauma. And now more recently thinking about design and using simulation for simulation form design. Chris and I recently started a company that does some of this work as well. And so, we toggle between the academic space and the, I guess, industrial space. Using simulation to help make better decisions and inform design of clinical spaces and outside of healthcare, we do some work and stuff. So yeah, it's really been a pretty interesting past few years.
Chris Hicks 02:49
I was born and raised in Toronto, med school in Kingston. Did my FR residency with subspecialty work in trauma back in Toronto. Again, I've been at St. Mike's for about 12 years now. You know, I guess how we got interested this. I speak for myself. I always had advice early on in my career to take something that really annoys you and make it your passion project. It's been my observation for a long time that, when things are difficult in a resuscitation or in clinical care, it's rarely because people don't know what they're doing from a medical, or surgical, or procedural side of things. It's because the logistics and the team dynamics and the so-called human factors of the situation, kind of, incumber us. I've come all the way through from the personal and team preparation side of things, to coming all around now to looking at the systems, and ergonomics, and design factors that influence performance. And I think it really started through our work in simulation, trying to optimize our own resuscitation environment, particularly in trauma, but also in a new emergency department. I say new, it'll be new one day. By the time it's done, it'll be ready to be renovated again. But it was working there and then realizing that there was a real appetite elsewhere for people to look at and examine the work that we were doing. And recognizing that we developed a niche little area of simulation in optimizing clinical environments. I'm sure we'll talk a little bit about what that looks like. But it basically arose from an itch that we both felt we really need to scratch around how annoying suboptimal work environments can actually be, regarding clinical care, regarding job and life satisfaction, and working on patients
Chad Ball 04:26
If I think back to 2009, when they were building the new tower at the Foothills Medical Center, and we put in a hybrid operating suite dedicated just for trauma, which we came up with the acronym of the RAPTOR. Andy Kirkpatrick and I, I'm sure you're aware of, published a fair bit about that human-centered design piece that went along with it. And to be honest, before that situation or that development, we were certainly very ignorant to that entire field. We were, no doubt, blind to it. The benefit and the interest that comes with it. I'm curious if one of you could define for our audience, maybe who is not savvy with this conceptual work: what is human-centered design and where do you go from initially identifying that it may be helpful to you or your group? I mean, human-centered design is basically an approach that you use for systems development, process development, space development, where the focus really starts with the end user. It's their needs and requirements and input that drives the design. So traditionally, interestingly enough, oftentimes, it's not-so human-centered design comes from non-users, often. Now, you'll see good designs, often, are linked closely with how a user experiences whatever the product is, or whatever the space or system is. But it's not uncommon, for instance, if you think in healthcare, an architect who never is a patient or is a clinician will be responsible for the design of a space. Traditionally, that's what's happened. And so this notion of putting the human, the patient, the clinical team, at the core, at the center of the design process, to first understand them, understand what it is that their needs are, and sometimes they don't even understand their needs. And we'll talk about ways that that can play out. And then, as a result, designing as such. We can look to tech as a pretty good example for human-centered design. If you look at most people's iPhone or Android devices, are so intuitive. They've clearly put the user at the center of it. I mean, my four-year-old is completely solid with using the iPad, and she needed no instruction to do so. You don't have to read a manual to get to that spot. And it's amazing that despite the fact that the iPad is a highly complex product, it requires really no instruction or, a little bit of trial and error, and that's about it. So, you can see quite early that with well-designed products, that if you put the human, if you put the user, if you put the, in healthcare, the clinical team or the patient at the center of it, then you really end up with some quite valuable outputs.
Chris Hicks 07:54
Sticking with the tech example, on the healthcare side, you don't have to look any further than almost every CPOE system to appreciate the impact of not focusing on the user when you design something. I think, and Andrew would probably agree with this sentiment, that things get designed for us with a need in mind. Your CPOE system needs to track patients, it needs to record clinical information, it needs to output clinical data. And so, designers go, "okay, well, let's create something that fits those needs. Here's your patient list and here's how you record, and this is where you get information." But it's the how. How you access that information, how it's used, how it's translated, that's missing. In clinical space, it's the same way. We need to put 36 patients in this emergency department, we need a bunch of stretchers to put them on, we need to have resuscitation equipment available. You know, the analogy to CPOE in our emergency department is not as much true, I don't think, in a surgical environment, in the operating room. We would observe, I think, that our clinical logistics are set up to facilitate stocking. We need to get stuff into the department, and we need to understand and track stocking. So that the department has stuff in it. What is missing from that process is how that stuff gets used by the end user. And that's the user-centered design side of things. Just having a bunch of stuff kicking around is not good enough if you don't also integrate how that equipment is used, where it's most likely to use, what pieces of equipment are likely to be used in concert with one another, how you get it to the bedside, how you use it safely, how you dispose it, how you restock it. All of those things are missing. And it doesn't take a lot to just ask a provider what it is they need. The problem is most people don't ask. We've gone so far in healthcare with just getting used to that predicament that I don't even think we notice it anymore. One of the interesting things about simulation is it just shines a light on that. You start looking at a problem that is there every single day of your life, but you don't pay attention to it. And this simulation form design process, that Andrew and I use, shines a light on that sense of learned helplessness that I think we've all become accustomed to. As surgeons, this is probably not as familiar to you. But you can imagine just, you know, your operative equipment just being everywhere, and you have to go get what you need ad hoc, that obviously would have a fairly significant impact on your efficacy in the OR. And that's an issue that we're trying to solve in a variety of clinical environments, both in and outside of the operating environment.
Ameer Farooq 10:20
Yeah, I love that, Andrew, what you said about your four-year-old being able to use the iPad, right? I saw a tweet the other day that was like, new developmental milestones should be for children that whether they can use the iPad by the age of two, right? So, it's so simple to be able to use. I was hoping, both of you talked about the fact that you noticed and had this daily irritation with how poor the design can be in the emergency department. And, like you just said, Dr. Hicks, that we often don't even notice how poorly designed our spaces really are. Maybe, starting with you, Andrew, could you just talk about an example of poor design in the emergency department?
Chad Ball 11:05
Oh, man, where do I begin? So, this would be, I think, common through any resuscitation space. And Chris and I have described this, and we can start with the location of vital sign monitors. The rationale for them being at the head of the bed, in all spaces, in all places of the world, always, is just a remarkable accomplishment, I guess, in the most broad terms. But is unbelievably effective. Meaning, you're blinding your airway providers, essentially, from the most vital monitors you have. Now, that might be okay in the OR, where you have a silent environment at the time of induction, when you can leverage your auditory sense and use the sound of desaturations. But, in any busy ICU, emergency department, trauma bay, the idea that we would only have one monitor with, it is literally called, a vital sign. So clearly, it seems important. That we would blind some of the team from that information, that would inform a change or pivot in process, is remarkable. These are just one of the few things. I mean, Chris also mentioned how the equipment layouts are structured for stocking. That's, I think, common. That's not just in the ED, I think that's throughout healthcare. Chris could probably weigh in on this, because he certainly has advocated more of this than I have. But the idea of how we communicate with overhead pages, as a strategy to, I don't even know what. I don't know what the strategy is, but overhead pages being a way of communicating information that really, in certain instances like a code white or a code blue or something, is effective. But to tell a team that a stretcher needs to be moved or cleaned, is remarkable that we would be polluting the bay and adding to distractions from people that are already cognitively overloaded. So, I don't know, Chris, what do you think? Those are a few that I've come up with.
Chris Hicks 13:30
Yeah. The example that I would use, with the notion of putting cart before horse, again, really, to the design of our emergency department. Where there was this really good concept that guided the design of our acute area, where we'd see our sicker patients, which was rather than having a single resuscitation space, every room was meant to be used for patient resuscitation. If you think about it, conceptually, that makes a lot of sense. If, presumably, you could put a sick patient anywhere and, in concept, looked after them equally well, in any of the 36 beds. Problem was that the logistics support that were just not there. Right? So, although you had a bunch of rooms that physically resembled one another, the logistics of getting resuscitation equipment to the bedside were just completely absent. This is a big emergency department, a big area with 36 beds, a long hallway, a lot of geography between the three zones of the area. The idea that you would be looking after a patient in one zone and have to cross three zones to the other side of the department to grab your central line kit and then come back. And then, having grabbed your central line kit. Get all of the related accoutrement that you would need to put in a central line. And then, go and find your ultrasound. And then, go and find your sterile ultrasound equipment. The patients up at the ICU are dead by the time you get it all together. So again, a concept, which is resuscitation everywhere, is a great concept. The problem is, and the step that was missing was, well why don't we ask the users what they would need to be able to resuscitate in any one of those spaces? And the solution we came up with was a mobile resuscitation tower that was duplicated in all three zones, which is meant to support the clinical logistics of resuscitation for the first part of 45 minutes of anything. That's sort of extraneous to the crash cart, this was more set up for things like central lines, and IV starts, and rare procedures like pericardiocentesis. And suddenly, you did have a solution that allowed you to resuscitate [inaudible]. But we had to reverse engineer that, going from a concept that sounded great, but just didn't work.
Andrew Petrosoniak 15:29
I guess, the other thing I would add on sort of poor design, our entire waiting process in healthcare. And I don't mean just in the emergency department, but everywhere that that is really focused on the clinician. I don't think many places do waiting very well. They're certainly not a patient-centered approach. The idea that you wait without knowing and spending most of your time not knowing what's happening. If you ask anybody that studies a waiting experience, if you dig into any industry that actually cares about the user experience, they very much keep people occupied, they keep people moving, they're transparent with waits. I mean, this is the antithesis of healthcare. So, I think that's probably one of the other things that is broadly applicable. Certainly, in the ED, in many places. But I think throughout healthcare, outpatient clinics, all of that.
Chad Ball 16:31
I love your examples a lot. I certainly see what you mean with each of them. I want to push back a little bit, though, against the notion that the emergency department is similar to other areas within a hospital. Having worked and trained for a long time in the US, at trauma centers, for example, if we surround the trauma side of things, with volumes 10 to 15-fold higher than the busiest Canadian trauma center, it's interesting to compare and contrast those two. Most of the trauma centers across the country that I've, personally, been in. And by that, really what I mean is that, if you compare the noise level, the patient flow, the number of bodies, the general chaos, I would argue, in many emergency departments in Canada, it's fundamentally different from the busier spaces in the US. There's a lot of postulates as to why that is. To be honest, most of the high-volume trauma centers, there is no emergency medicine involved at all. If you start in Cape Town and you work your way back to North America, you tend to come in the door and if you're injury you go one way and if you're anything else, you go the other way. What's amazing in these centers is, you can have 6, 8, 12 gunshots sitting in your trauma bay, and the environment is quiet. There's many, many, many less people and the flow of care and the quality of care, I would argue, is significantly higher. When I think about the environment that I work in, for example, and how we address similar scenarios with regard to critical illness or intensity of illness, again, there's a fundamentally different approach in the emergency department, compared to the critical care suite, compared to the interventional radiology suite, and compared to the operative suite. And a lot of those same comments do apply in comparison. It's, as a result, really been a challenge for us, certainly locally, and I know, in a number of trauma centers across the country, to try and solve some of those issues. We certainly have not approached it with a more novel human-centered design, as you guys are talking about. I'm curious what your thoughts on those comments are and maybe the differences between the emergency department in these other areas, as well as your insight into how you start this process in a constructive way, in a multidisciplinary way, across different centers.
Andrew Petrosoniak 19:17
Well, I think we would agree with you on the notion that every area of the hospital is different. And fundamentally, I think that's part of what simulation-informed design can help with. Solving your clinic logistics issue in the ICU is going to look different than the emergency department, depending on what the nature of the problem is. I think Andrew and I would be the first to say, you have to spend some time figuring out what the actual issue is before you go trying to solve it. We're awfully good, in healthcare, at trying to solve problems we don't really understand just yet. So totally agree, I think you're gonna get a different look at the nature of an issue in the ICU, versus the trauma room, versus the emergency department. If we, and I'm sure we'll get into this, this notion of importing concepts from design thinking into clinical just sticks, the first stage in that whole process is empathizing and understanding and getting a sense of what the nature of the problem is, before you actually start to create solutions. Whereas, generally speaking, I think in healthcare, we get that backwards. We start trying to solve problems that we don't really understand. So total agreement there. When we talk about solving issues like crowding and noise, I completely agree. I don't understand why our trauma rooms function in a noisy, chaotic, haphazard way. When in reality, what happens there, compared to the rest of the emergency department, comparatively predictable and systematic and organized. You know you're getting an injury; you just don't always know what kind. And is a relatively reproducible process that needs to take place for every patient, every time, with a team that, apart from the individuals, relatively has the same composition most of the time. So why it descends into chaos so often is a little bit beyond me. Except to say, I don't know that it is, because we've spent a little bit of time trying to figure out what the issues are and how to solve them. So, I think the first thing Andrew and I would advocate for, speaking in particular, we'll leave maybe the team training and team dynamics aside for the for the moment. But we do believe that there are ways in which you can engineer your space to allow you to get more out of your team that you want and less of what you don't want. So, for example, if you look at the work in our trauma bay, we've created behavioural nudges to help create social and team norms that allow us to reinforce the behaviour that we want. So, there's a circle of care around the patient's head and torso, and that's been in trauma in particular, to protect the very valuable real estate around the head, neck, and torso. People don't necessarily respect the circle on the floor. But what it does establish is, if you're not rendering clinical care and you're inside that circle, people are empowered to say, "Hey, step outside of the circle because we need access to get IVs." And one of the big issues that you've probably seen as well, is nurses and trauma team members kind of jockeying for space. Doing a point-of-care ultrasound in a stable patient when it's not really relevant, when what you should be really doing is IV access and bloodwork. So, that allows, for example, our nurses to say, "Hey, can you please stand outside the circle of care because you're not directly involved with hands-on patient care." That's the same for floor markings we placed on the ground that helped to create some social norms around where you stand, where you don't stand. Crowd control: we've created a viewing room adjacent to our trauma bay, so that when things start to get noisy and people are just standing around watching, the so-called redundant tissue of trauma team hangers-on, we can kick them out and have them go across the hall to watch. So, all of this in service of creating some systemic interventions and nudges to push us more towards the behaviour that we want. It's one thing to just walk into the trauma and say, "Everyone be quiet!" But it's another thing to say, okay, this is how we're going to shape and mould team behaviour, to get a bit more out of what we want from the team and a bit less of what we don't want.
Chad Ball 23:02
I guess the other thing, on that note, is that if you design the space more effectively, and more efficiently, and more intuitively, then you can start to eliminate other distractions and streamline cognitive load. We can start to eliminate noise when we don't have people yelling, "can you get me something?" One, if it's easier for somebody to find, then you've suddenly eliminated a need for communication, in that point Obviously, there's some team training stuff where you can task delegate, so you're talking about the design and construction of a team. But I think we forget how much communication is required to overcome the deficiencies in the design of a physical space because people are asking for things, they can't find things. That creates a sense of urgency, it increases noise volume, it increases stress, it impairs decision making. All of these types of things when, if we simply had most equipment readily available, we weren't putting equipment on patients' chests as the table. We weren't losing stuff; we couldn't find things. Then, we suddenly are in a whole better headspace. It's like when you lose your car keys and they're right in front of you, but you're frantically trying to get out to some appointment, and you just can't see them. The same thing happens when you're stressed out in, whether it be a trauma, or an OR, or an emergency department. If you can't find things, it's quite stressful. And then, it just compounds and it's a vicious cycle.
Ameer Farooq 24:44
We've done a lot of work to actually study what the challenges are, what the problems are. Because, I think we all have this idea that we know what the challenges are and what the problems are. But, unless we actually sit down and look at it, I don't think that we actually really know what is actually happening in our emergency departments. So, when you're thinking about a design type problem, and you're trying to understand that what goes into actually dissecting the problem, if I can use that term, and actually understanding the problem? How do you actually go about studying design in a healthcare setting? And maybe, Chris, you could start us off?
Chris Hicks 25:34
This is a good segue into the design thinking philosophy. Again, you say we understand the problem, I don't know if we do. I think we understand that most of us, if something isn't working right, we know that it isn't working right, but we don't always know what about it isn't working. I think that's the challenge and that's the part we don't tend to examine. We say, okay, it takes too long to get blood to the bedside during massive resuscitation. Alright, let's jump forward to the solution. We're going to educate everybody and send reminder emails on what the MTP or the MHP process is supposed to look like. There's our solution. We will remind people and remind them again, and remind them again, and it's still not going to work. Taking a design-thinking approach, and obviously we didn't create this, but using it in the healthcare space is relatively novel. But this notion that you would spend a little bit of time, I know it sounds crazy, we spend a little bit of time trying to figure out what the nature of the problem is, that empathize and understand first, and get input from multiple perspectives for a given problem. So, not just speaking to leaders and administrators, but frontline providers, doctors, nurses, CAs, what we call USWs in our environment, porters, everyone. Talk to everyone and get a sense of what they're doing. And better than talk to them, use simulation to really understand and observe the work that they do. Not just work as imagined but work as it's done. Make those observations, discuss, debrief, analyze. Now you have a pretty good sense of what the issues actually are. And using that MHP example, and this is Andrew's work, working on optimizing massive hemorrhage protocol. You find out peculiar things like, the porter who was supposed to get the blood, we don't have blood in our trauma bay, it has to be fetched, was walking down the hallway, waiting for the elevator, going up an elevator, walking down another hall, coming back, waiting for an elevator, going back down the elevator, walking back. That's not that person's fault, they just didn't understand: one, every minute of delay to getting blood to the bedside incurs some increased degree of mortality. And two: if they went up the stairs, it would be a whole lot faster. So, we would be totally blind to that idea if we didn't try and look at it and examine it first. And then, once you have a sense of what the issues are, and what the problems are, then you move on to ideation and prototyping. You're still not solving a problem yet. You're coming up with solutions and proposals and prototypes and testing them to see if you actually get the result that you think you're going to get. So again, still a long way away from actually resolving the issue. You know, one of our greatest strengths in healthcare and one of our greatest weaknesses, and I think surgeons and emergency physicians are similar in this, is we're very problem focused. We see a problem; we want to fix it. We skip a lot of steps in between. Andrew and I would say the warmup to solving a problem is probably more important than solving the problem itself, in terms of process. So, we're still at the notion of ideating, prototyping, testing solutions, trying to figure out what's gonna work. And again, Andrew and I, being simulation people, would both say that a simulation-informed design process is a very powerful and useful way to do that, for two reasons. One, obviously, if you run a simulation, you have the opportunity to speak to, and discuss, and debrief with participants afterwards, to really get into their heads. And the simulation side of things helps you harness their sense of engagement and participation. And specifically, we're talking here about in situ simulation, where you're putting them within their work environment and doing their actual work, not just what they think their work is, but actually doing it. So, you can speak to them, and discuss, and debrief. But you also have the opportunity to watch video and data from afterwards. Things that people would never notice on their own, you have the opportunity to look at, and observe, and show them, and reflect upon. It's like an athlete watching the tape from their performance. They're like, holy crap, I didn't even know I was doing that when I went to the boards. So, you get those two very powerful data streams. You put them together, and now you really have a sense of, okay, we had three ideas for fixing this problem, only one of them actually seems to work, and is time efficient, and cost efficient, and cost effective. Now let's move ahead towards stage three, along design thinking, which is implementing and observing, and the CQI process that moves forward from there. You're not done yet, you have to implement it and get people on board, and make it work, and develop a system that allows you to implement a given solution. And then, you have to monitor it in an ongoing fashion to make sure that it actually works. So, I think we do a fair bit of that last thing, which is implementing stuff. But we don't do a lot of the prototyping, ideating, empathizing, and process development before we actually get into the implementation stage.
Chad Ball 30:14
I just want to focus in on one of the things that Chris said, which is so important, is this idea of the multi-pronged or multi-faceted approach to understanding a problem. And we studied this when we were looking at how people work in our trauma bay. It is insufficient for, if you really want to understand a problem, it is insufficient to ask people what the problem is. So, it is a good idea, as Chris described, in a debriefing, to ask them what their perspectives are. We should never divorce that from the process. But there are many things where the end user is blind to or ignorant to, because they're so engaged in the process. For instance, back to the monitor example that I gave earlier, the idea that you have monitors at the head of the bed and the airway team is physically blinded from the monitor. When you ask people, did you notice the oxygen desaturations? They say yes, because at some point, they did notice it. But the monitor was... it had already happened. That had been, you know, a minute or two delay. So, you may solve a problem lateral to the actual problem if you don't fully understand it. So, when we asked people in debriefings, "Tell us about the encumbrances you have in your space." They would say things, people talk about people. It was like, we published on this, we documented it. People will talk about interpersonal conflicts, how the communication went. That's what people recognize. We are not accustomed, in healthcare, to think and reflect on how we interact with physical spaces, processes and systems. And so, when we debriefed people after running in situ simulations, we said, okay, tell us what latent safety threats were there. What prevented you from doing your care? It was all about, "Well, I had a bit of an interpersonal conflict with my colleague here, but we resolved it," and all that. Whereas very rarely would people talk about equipment issues. No one ever mentioned the four cords they tripped over, the equipment they lost or couldn't find. So, it's a remarkable display and predictable behaviour in healthcare, probably in other places in the world, in other domains. But we cannot exclusively rely on asking people. We need to ask people what they experienced. That needs to be coupled with direct observation, that needs to be coupled with other advanced metrics, some data on how they move, where they go, where they're looking, to really understand. And then you can start to, as Chris mentioned, ideate, and prototype these through some simulation. That's such an important point. And you guys have thought about this, clearly, so deeply. And there's so much we can learn from you. You know, one of the anecdotal, interesting, experiences here again, at the Foothills, take it back to the RAPTOR hybrid OR, was that we had the benefit of a shell space. So, our engineers had built plywood mock-ups and to your guys' point, we ran multiple simulations of multiple different injured patients. And it was absolutely incredibly important not only to debrief with those personal opinions. But as you point out, we had fixed cameras in all locations, looking at pinch points and physical flow, and how that would all optimize care. I guess, what I'm getting at is, tell us what your thoughts are in terms of maintenance of these sorts of environments. Because our experience here would have been, again, all this front-end work went in, it worked very well for a while, and then we saw creep over time, of some of the same issues. Less so about the physical plant or the physicality of it, because the room had been designed so well. But more, sort of, other issues. And you guys have touched on a lot of the potential categories of those issues. But I'm curious what your thoughts are in terms of, all this work goes into optimizing the space and all the human factors work. And then, you're two or four or ten years down the road in that same space, with speed bumps along the way.
Chris Hicks 34:53
Yeah, I mean, and two things. One, my first thought, and we've encountered this with our work, even with all of the process that Andrew and I just described. You do all this work, you think you're getting things right, you implement a solution with a design-thinking and user-centered lens. And it works great for a period of time, and then it doesn't. That actually makes me wonder if we got the right solution in the first place. Because what we should be doing is making the preferred behaviour the easiest thing to do. And if you watch people slipping away from the preferred behaviour, it's easy to blame the people. It's easy to say, "Well, why don't you just use the space and the equipment the way we designed it for you?" But every time I catch myself saying that, I think, but maybe we just didn't get it right and we have to revisit it. So, my first thought is, when you start to slide back, have you really made the preferred behaviour the easiest thing to do, or did you create something with a lot of effort that looked good for a period of time, but over time, just decays and doesn't work? There certainly is a role for periodic refresher training, and revisiting. Medicine changes, surgery changes, and equipment changes, and you have to update all of that over time. So that's part of it. But I find, and you mentioned the resus tower, it's a good example of that, once you create this pretty looking and functional tool to facilitate resuscitation logistics, after you rip it apart in a resuscitation for two hours, somebody has to put it all back together again and restock it. And where we fall down, often, in the emergency department in general, is with our restocking process. This is an issue as old as time, getting equipment restocked. We realized, in that particular scenario, we had to go outside of our standard restocking system and create a restocking system that worked on the fly. That was done by a clinical person, because it is kind of a clinical tool to put it back together, as opposed to somebody from Central Stores. And then, because our tower is colour-coded and bundled, we set up a whole other restocking area and restocking process, that mirrored that same colour-coded system. So it was, comparatively, easy to put back together, versus what you might find elsewhere in the department. But it still takes a lot of time, and the process right now is still hinged on, for right now, a nurse. So, after resuscitation, a nurse comes out of circulation to put the tower back together. And it really does, if you really pull it apart and use everything in a resus, for a couple of hours, you're talking about a good 30 minutes of restocking. So, it's not a small thing to take somebody out of circulation. So, I look at that and I say, we kind of fell down on the second part of the process. Which is, you think about that nurse that has to restock that tower, that nurse is busy. That nurse wants to get back to clinical care. They don't want to spend a ton of time restocking a bit of clinical equipment when they have patients to look after. And so, they're going to, again, from a human-centered design process, they're going to take shortcuts, they may skip certain things, they may get 90% of the way there and then say, "Ah, screw it, this is good enough, let's just put it back in circulation, I have patients to see." That's totally understandable and the wrong approach to that would be to say, "No, you have to stock this thing properly." The right approach would be to say, "Well, what else can we do to make that process easier?" And so, using that as an example, we are looking at getting our equipment bundles put together in Central Stores, so that rather than having to put it all back together, you just have to grab a bundle off of a shelf and put it back in the tower. That's one potential solution. And another one is just not having a nurse do it at all. But to have one of our CA's, our clinical assistants, do it so you're not taking a nurse out of circulation. So, all that to say, you know, if you're as happy as we were and as proud as we were, frankly, of putting something like the resus towers together and all of the process work and simulation-form design that went into it, I don't know that the end process was really right, when we watched it play out in real time. And so, rather than saying to people, as we often do in medicine, you have to do this thing because we want you to do it. I think sometimes it requires some sort of critical reflection and getting over our hubris a little bit and saying, "Well, did we really get it right or do we have to go back and re-examine the problem and find out something else that works?"
Andrew Petrosoniak 38:54
I think on that note, Chris, because I think that's one of the, probably, key things about this are that we should never expect a design process to be static or finite. In that it should always be dynamic and probably iterative. Just as much as we have multiple prototypes until we get to the "end product". We will learn over time that people will evolve and change their behaviour.
Chris Hicks 39:22
The reason we're on the iPhone 12, right? And not just the iPhone 1 right now.
Andrew Petrosoniak 39:26
Exactly. Or, you look at, I think, well, this happens to me all the time, which maybe speaks to my addiction to Twitter. On Twitter now, if you scroll long enough, it says, that's the end. It tells you that you've read as much as there is. They've built this in because they had a wonderful product, all of this information could just be forever, you could be on that device. And yet, they have realized, well, maybe that's actually not that good of a thing. And so, we have to now design a stop point to kind of nudge people to leave that page or whatever it might be. So, I think even good designs might have unintended consequences. And Chris has outlined them in using the resus tower example. But we should never imagine that this is a finite process. But rather, it is dynamic and continues to evolve as much and as complex as the teams are, that are using it.
Ameer Farooq 40:36
Yeah, there's a real humility to this whole work that you don't decide how people should do things, but you look the other way and see how people are actually using it. I'm glad I'm not the only person who has scrolled to the very bottom of their Twitter feed and had to be reminded, hey, maybe you should be doing something else, you've gotten through the entire timeline on your Twitter. So, I'm very happy that I'm in good company. So, we've been dancing around all the work that you both have done to redesign St. Mike's trauma bay. One of the reasons I reached out to both of you was, we saw the pictures of the new St. Mike's resuscitation bay. And I had actually come to St. Mike's a few years ago for my colorectal surgery elective, actually, and had done some call and seen what the trauma bay was like beforehand. And it just looked radically different and is beautiful. So, I was hoping maybe Andrew, you could start us off. Can you walk us through what were the things that you noticed, in particular, about the St. Mike's trauma bay and some of the big things that you worked on and improved? You talked about the resus carts and some of the other things like the circle on the floor. What were the other things that you noticed about the trauma bay, that you worked on and improved?
Chad Ball 41:55
So, the biggest one was understanding the size of the physical space. The actual original design called for three beds. That was built out of some calculations that we would have an increase of, we'll call it, 50% of trauma patients over the next, whatever, 10, 15, 20 years. And so naturally, if you have two beds and you were expecting an increase of 50%, you would go to three beds. That makes sense. Though, most of us, and all of us here, understand that it's not like you fill those beds every minute of the day, for 24 hours, 365. It's that, over the period of 24 hours, you'll have, instead of five patients, you might have seven or eight. And so, what we realized was, when we studied in our existing space, we understood the circumference of care required for a trauma patient. Where are the clinicians moving around in the old trauma bay? We understood, I can't remember what the dimensions were, but it's something like eight feet from the surgical center of the patient. Well, when you put that in, when you laid out three stretchers in the new trauma bay, you would have overlap. And you would actually be creating encumbrances and creating, probably, people being upset that they're running into the stretcher adjacent for no good reason. And so, as a result, we brought this to the architects and to their credit, they redesigned us a space where we now are still at two beds. I mean, I'd love for three or four or ten beds, but only if it could accommodate that. So, we were able to reconfigure the booms. This saved money, this saved time, this saved retrofit costs, this saved frustration among clinicians. So that was probably one of the biggest things, is just understanding the space accurately and then being able to design it appropriately so that it fit our needs. And still allowing us to do the job that we need to do and getting care delivered in a timely fashion. Other things that we did. We went through a list of processes that occur regularly, or procedures, or things that happen. Chris can probably talk about some of the cart development, because he did a lot of that. But we built, what we call, a high-frequency cabinet. So rather than scattering equipment all around the room, there are things like, we often staple or suture fairly quickly, we'll need saline for irrigation, we'll need pelvic binder, we'll need sterile gloves, whatever. All of that kind of stuff. Yet, we don't typically need a Thomas splint for reducing a femur fracture or something. We need that, but we don't need it urgently and we don't need it frequently. And so, we reprioritized and reorganized that space so that the clinicians could find stuff and we stratified it in a way of frequency. So, we have a cabinet that has, what we call, the high-frequency cabinet, that has all of that equipment that we need regularly. It's all labeled in a way that makes sense. So, you can find it from anywhere in the room. What else did we do? I mentioned the monitors. So, we observed that there was a functional blindness that was happening with the vital sign monitors. So as a result, we put monitors at the foot of the bed as well. So that the airway team could visualize the monitors, we put monitors at the side of the bed. So, we have 270 degrees of monitors, so that pretty much anybody taking care of that patient has an easy sight line to the monitors.
Chris Hicks 45:44
To give you a sense of how it played out. This all started in our old trauma bay. So, we started by running in situ simulations in our old trauma bay. We created what we called, living M&M cases. Which is, we mined our hospital's true M&M database for unanticipated trauma deaths. We organized those into themes. And then we created simulation cases based on them, when we ran them in our old trauma bay. And what came out of that, again, this is on that empathize and ideate stage of design-thinking, is we were able to get a list of themes in general issues. Like, when somebody says, "We're going to perform a surgical airway," that may mean a percutaneous airway to the anesthesiologist, it might mean a bougie cric to the emergency physician, it might mean a tracheostomy to the trauma surgeon. Nobody's thinking the same thing and there are three different kinds of equipment organized haphazardly around the trauma bay. So, there was a lot of confusion around that. Issues around time of blood product delivery. Issues around space around the head, neck and torso. Challenges around clinical logistics, and patient and provider safety. You know, again, all that work went into understanding what the nature of the problems were, before we then went ahead and started to create and ideate and develop solutions. And so, Andrew had mentioned some of the work around space and protecting the real estate around the head, neck, vital signs, monitors. I think he's kind of underselling the importance of the work he did around rethinking clinical equipment. I think our take would be that every bit of equipment in our old trauma bay had, if you were to give it a weighted priority, had the same weighted priority. Whether it was a Foley catheter, or a percutaneous airway kit, it was all kind of weighted the same in terms of your ability to find it and use it, which makes no sense at all. So, we recategorized. We said, well, really, there's three kinds of equipment in trauma resuscitation. There is bedside critical care equipment, things that you need to be able to bring to the bedside, to do something like a finger thoracostomy, chest tube thoracotomy, whatever it happens to be. Then there's stuff that you use often. And then there's everything else. Okay, now that we understand that, let's start to design solutions that actually work to execute that design concept. And so, the bedside critical care stuff was, the carts that Andrew refers to, carts with giant words on the side that say, "chest tube" or "vascular access" and "arterial monitoring". You know, stuff to facilitate REBOA, if you believe in that sort of thing, I won't go there today. But the idea is, you have a cart that has a purpose, and it's easy to find, and it tucks under a cabinet. And from anywhere in the room, you can look around and see these giant letters that say, "chest tube" on it. And you know what it's meant to be used for. That can wheel to the bedside, it has a stainless steel, large work surface on it. So, you're not putting equipment on the patient's pelvis. Somewhere in the world right now, somebody has a central line kit on somebody's pelvis, about ready to get kicked onto the floor. We did that because we had to, or because the alternate is a Mayo stand, which, as far as I can tell, was designed to fall over. So now we have this thing that actually facilitates the work that you have to do at the bedside. It's easy to use and it's intuitive, and has everything you need, and that's it. And that's true for central line access, and femoral artery access. We've restocked and reorganized our airway carts so that they're process based. If you look at our airway carts, they say plan A, plan B, plan C. By the way, that's a deal that we totally stole from Mike Betzner, who was one of your best and brightest. We took that from the DAM card design that they've used out there. And a great name for an airway cart, I have to add. But again, it's process based. We understand that if you open up plan A, then there is a plan in place. And we can actually train our teams and design our equipment in our clinical logistics to reflect what plan A is. We don't have to wonder in advance and create ad hoc what our first airway plan is going to be. It's relatively standardized. But the point is, all of that is bedside critical care. And now we get it, and we can design a solution to work for it. Then, as Andrew mentioned, there's stuff that we need often, but we don't need it at the bedside. That's where the frequency-use cart is. Again, it's colourful and it's labeled, and it's relatively easy to identify. So, if you have a patient with external hemorrhage, you open up one particular shelf in the cart and you have everything you need for external hemorrhage control. And then there's everything else. Everything else can go away. It could go in a sterile storage room. It doesn't have to be at the bedside. As Andrew said, casting and splinting, with apologies to orthopaedics, often they're not emergent. So, you can take a minute to go and find that stuff. So, everything is not weighted equally. Everything doesn't have a weight of one, we've weighted certain things heavier than others. And then we turned around and created design solutions that actually facilitate the clinical logistics to get that critical care to the bedside.
Ameer Farooq 50:18
This has been an absolutely fantastic discussion with both of you, I've really enjoyed it. So many of the concepts that you're talking about are so important. And yet, surprisingly, so foreign to most of us, as you both alluded to. This whole concept of design-thinking, putting the end user in mind. It's very different often, I find, in the way we traditionally do research in healthcare. Where we do this big literature review, and we look at every single research report that was ever written about the topic and then, make some tiny little incremental change, which really doesn't solve the problem, often. Because often, we don't even know what the problem is. So, thank you again, both, for joining us. I wanted to end by asking both of you what you think the future of human factor design is, particularly in the emergency department, but perhaps even more broadly, in the hospital? And maybe we'll start with you, Andrew, again, what do you think are the big challenges going forward? We talked about the fact that design is not a static process, that it's a dynamic thing. And obviously, your context might be different than other things and other places. But what do you think are the big challenges, big things, that you both are working on, going forward, that need to be solved for the 21st century and beyond?
Andrew Petrosoniak 51:34
I think the idea that, when we say human centered design in healthcare, that the patient becomes involved in that design process. And I would be shocked if there's many places in the world that are designing with the patient not in mind but involved. I just don't think that it's happening. I mean, we see this because people get frustrated in their receiving clinical care. So clearly, we have dismissed their opinions. And so, we try and imagine, as clinicians or as designers, as architects, whatever that might be, whatever level you're at, you might try to imagine what the patient would want. But until you're lying in pain in a trauma bay, or being wheeled to the OR, or waiting for an outpatient clinic, until you actually experience that, then it's very difficult to know what's actually needed, what's actually the problem. The other thing is, this idea that we would ever open a new clinical space with a patient being the first test case of that space, is a remarkable failure in healthcare. The idea that we would ever get into a car that hasn't been crash tested, it's not even allowed. I mean, there's regulations against that. And yet, we have no regulation that simulation isn't absolutely required, at the bare minimum, just to test prior to opening. Chris and I, obviously, advocate for simulation and Dr. Ball mentioned that what they've been doing in Calgary with the design of the RAPTOR suite, that it starts very early on, and you develop mock-ups and prototypes and all of that. But at the bare minimum, that even just before it opens, that it'd be tested, so that at least you expose any of the design deficiencies. And then, the usual workarounds, that we're so good at in healthcare, can be implemented. But I think those are the two main areas that I see as, I guess, challenges and opportunities that patients be involved in the design process. And I would say, I guess, the same clinicians, if you ask and you follow the current processes, a handful of end user meetings, and then plans get drawn and that's the end of the story. And then before you know it, the shovel's in the ground. Which is, I think we spend a lot of time in the solution space and not enough time in the problem space. And so, if we can fix that asymmetry, I think then we'll be in a better spot and our patients will be getting better care.
Chris Hicks 54:24
Yeah, Andrew and I think a lot alike on this, so no surprise we'd give the same answer. The idea that we are developing, and opening, and creating clinical spaces and systems without crash testing them first or worse, still, putting real patients in the front seat and then crashing the car. I mean, that concept just seems completely bonkers to me. And I think healthcare in general has a lot to answer for, with this concept of learned helplessness that we've all become accustomed to. We can't see it because we've been told that this is the way it is. That we have to accept that work is the way it is. That medicine is hard. That it's supposed to be difficult. And even worse than that, we're often commended on our bravery and our resilience in working against stupid systems that weren't designed to work for us. So, I think there's a lot to undo there, where health systems, in general, have been created on the backs of the effort and the resiliency and the ingenuity and the creativity of the people working within it, who constantly have to get over and problem solve around a system that doesn't work for them. That's not how it's supposed to be designed. You're supposed to design a system to make it easier to take advantage of the expertise of the people within the systems, so that they can look after a patient. We say that, but we don't actually do it. And I think one of the big challenges to overcome, in addition to what Andrew said, is the idea that it requires an upfront investment. We've had countless conversations with people that are interested in this work, and they want to find out a little bit more, and then we explain it to them. And we say, "Yeah, you have to do a lot of upfront simulation and testing and design and piloting and revising, and it takes time, it takes effort. Frankly, it takes money. But that upfront investment gets you a much better, safer, robust end result." Some people get it, and other people say, "Well, that sounds a lot more complicated than having a couple of meetings, so we don't want to do that." So, it's the classic challenge of preventative health or public health. The idea that you can prevent something by making an upfront investment and preventing a downstream catastrophe. You know, people's minds don't always think that way. They see the problem in front of them and not the opportunity to prevent the problem that's 10 steps away. And so, I think Andrew and I have a lot of work to do, and the system, as a whole, has a lot of work to do in trying to get people to see that an ounce of prevention is worth a pound of cure, right? We really have to help people refocus on, one, things don't have to be as screwed up as they are, we've just accepted that they are. And two, that it requires work and time and effort up front, to make sure that you actually get the safe systems that you want to get, as an end product.
Ameer Farooq 56:56
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. This podcast was edited and produced by Tyler Daniels. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your thoughts, comments or feedback. Send us an email at [email protected] or tweet at us @CanJSurg. Thanks again.