AHRQ Web M&M Examines Errors in Sepsis Management

The latest issue of AHRQ Web M&M includes the case of a 72-year-old woman with pulmonary hypertension, chronic obstructive pulmonary disease on home oxygen and coronary artery disease who came to the hospital experiencing abdominal pain on her left side and shortness of breath. Upon being admitted, she was also diagnosed with pneumonia. The patient was treated with normal saline in the emergency department, but was not given additional intravenous fluids because of her history of pulmonary hypertension and coronary artery disease. Twenty-four hours after admission her blood cultures were growing methicillin-resistant Staphylococcus aureus. Her condition worsened to the point that she required mechanical ventilation. Following a decision by her family to withdraw life-sustaining therapies, she died during her fourth day in the hospital. In the Perspectives on Safety feature, John Birkmeyer, M.D., chief academic officer and executive vice president at Dartmouth-Hitchcock Medical Center, talks about his video study, which found a link between practicing surgeons’ directly observed technical skills and surgical outcomes. An accompanying perspectiveexplores the advantages of using video in clinical practice and health care education.

Video to Improve Patient Safety: Clinical and Educational Uses

Perspective

by Yan Xiao, PhD; Colin F. Mackenzie, MB, ChB; and F. Jacob Seagull, PhD

Reports of the use of Google Glass in surgery (1) may mark a new frontier in the use of video in medicine. Of course, there is a long history of such use. Nearly a century ago, Frank B. Gilbreth, a pioneer of industrial engineering, filmed cases in the operating room to study surgical motions.(2) Recent advances in video-based assessment tools for a variety of surgical tasks (3,4) have created new and exciting ways to use video to promote learning, credentialing, and continuous improvement.

What makes video so unique as a medium for clinical and educational use? Improvement in patient safety often relies on understanding of human and systems factors that contribute to preventable harms. Video captures the rich context surrounding care activities, such as tools, equipment, and team interactions.(5) In contrast to administrative records, patient charts, and incident reports, video provides unvarnished and detailed records to allow examination of sometimes subtle yet critical contribution of human and systems factors to patient safety, such as the content and organization of instrument trays (6) or the effect of not tying a surgical gown properly (Video). Trauma teams have benefited from review of previous cases by identifying defects in teamwork (7), just like professional sport teams that routinely use video to review their past performance.

Video is efficient in conveying often complex tempo-spatial and context information necessary for performance feedback and assessment, especially in surgical procedures.(8) It can also capture the subtleties of interpersonal coordination and interactions.(9) Review of video recorded patient care interactions, especially when supplemented by the input of coaches and peers, can accelerate learning in both trainees and practicing clinicians. Birkmeyer and colleagues recently demonstrated that video captures sufficient information for peers to reliably assess surgeons' technical skills, and that such assessments are predictive of postoperative complications and mortality.(10)

With all of these advantages, why has video not been used routinely in clinical practice and in health care education? In the past, there were a number of technological barriers, but these have come down precipitously. The costs of capturing, storing, archiving, and reviewing video have fallen enough that they are far less of an obstacle than they once were. Mobile phones can now capture high-definition video. Efforts needed to address medico-legal and privacy concerns are often cited as a barrier to video recording in actual patient care.(11) Here too, technological innovations can help, such as automated removal and blocking of patient identifiers. Notification that video surveillance occurs in patient care areas is usually included in hospital admission and treatment consent forms to advise patients that photographs or video recordings may be taken for security or health care operations purposes (e.g., quality assurance).

Objections from clinicians often arise from fear and uncertainty associated with video recording. These objections can often be addressed by open discussion regarding the purposes of video recording, procedures for uses and timely deletion, and safeguards to ensure its use as a tool for learning and improvement. However, we should expect increasing concerns over privacy and regulatory requirements for surveillance use of video (blackbox recording) of care activities, even though video archives may support systematic studies and detailed investigative efforts.(12) Future advances of technology to minimize privacy concerns and to efficiently identify and compile video segment of interest may promote wider surveillance use of video.(13)

A number of forces exist to push for wider use of video to improve patient safety and quality. Transparency and accountable care demand validated methods of assessing providers' skills—both technical and nontechnical. The quality and patient safety movements have generated strong interest in learning and measurement. Current paradigms in education have emphasized the need for objectively defined competencies. These and other forces should bring about innovative uses of video to improve patient safety.

Organizations and individuals are increasingly embracing the use of video for learning. One type of use is how-to videos. As an example, a search for "central venous line" returned over 8000 videos on YouTube, one of which (on placement techniques) has nearly half a million views. Halsted's "see one"—as in "see one, do one, teach one"—is increasingly achieved through video. In addition to illustrating technical procedures, video is used for dissemination of best practices, such as bedside shift change reporting, and for instructions of how to operate devices (such as infusion pumps) safely. We should expect more pervasive use of how-to videos, with contents provided by peers and others, accessible through mobile devices and with user-friendly methods of retrieval (e.g., by scanning in-context QR codes). Professional development staff and educators are likely to be charged with vetting and publicizing educational video materials.

Another type of use of video for learning is to illustrate what not to do (14) or what can go wrong (seeexamples).(15) By teaming up clinicians with human factors specialists to develop video content, many organizations have begun to create vignettes illustrating some of the difficulties that clinicians have faced with certain tasks. Such videos can be powerful ways of demonstrating the risks to patients if certain tasks are performed incorrectly.

Structured, routine post-action reviews, either by individuals or by teams, are also becoming more prevalent. As more validated assessment tools (3,4), clinical protocols, and benchmark performance data become available, individuals and teams can structure videotaped performance review to enhance learning. Ideas such as crowd-sourcing (16) and peer reviews (10) may increase interest in routinely archiving videos (e.g., video registries) for individual and community learning. As opposed to complete encounters that may last hours, extraction of brief but most critical video segments—especially during interventional procedures with high risk—can make video review efficient and productive. In the study reported by Birkmeyer and colleagues (10), video was edited to show only critical aspects of the surgical procedure. Joint review with human factors specialists and others may gain important insights into expertise and identify opportunities for improvement.(17) We should expect technological advances in automated annotation and analysis, in collaboration with human performance experts and computer scientists.(18)

The Birkmeyer study (10) raises the possibility of yet another use of video: to identify a need for remediation or even (re-) credentialing. We have seen increased interest in developing validated assessment tools, which should lay a foundation for objective assessment of technical skills beyond quantity indicators (e.g., notarized case logs). Of course, this work requires substantial additional study and validation.

What one learns from video recordings is not always predictable. In one case conference in which video vignettes of trauma patient resuscitation were shown, a senior clinician was surprised by how often junior faculty members and residents picked up subtle aspects of expert performance that they did not notice during the actual resuscitation. In the video review of a prolonged esophageal intubation, audio communication details and timing of actions revealed that a medical student was inadvertently entrusted with the task of auscultation to confirm tube placement.(5) These sorts of insights help explain why the integration of video into improvement and safety activities is so exciting. In sports, there are now software programs that can review a golf or baseball swing and compare it against experts, highlighting where the technique deviates from the ideal. Automated identification of key video segments (such as visualization of hepatic duct during laparoscopic cholecystectomy [17]), combined with automated review and feedback, should accelerate expertise development and perfection.

Yan Xiao, PhD

Director

Human Factors and Patient Safety Science

Baylor Scott and White Health

Colin F. Mackenzie, MB, ChB

Professor and Faculty

STAR Research Center

Department of Anesthesiology

University of Maryland School of Medicine

F. Jacob Seagull, PhD

Assistant Professor

Department of Learning Health Sciences

University of Michigan Medical School

References

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Video

Video: Brief recording taken from actual patient care in which an improperly fastened surgical gown, coupled with the location of the instrument tray, contaminates the surgical field.

(Go to video citation in the text)