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Bill Papantoniou
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Hidden aspects of the anaesthesia chart 
Bill Papantoniou
ABSTRACT
Background: Anaesthesia is a complex task operating in an uncertain environment. Part of the problem is that many of the technologies developed to assist the anaesthesiologist hinder rather than help, because of increased complexity. Methods: We conducted an ethnographic ergonomic analysis of the domain in view of redesigning the anaesthesia chart as a digital artefact.Results: We uncovered the real use of the anaesthesia chart in the anaesthesiologist’s practice, as well as the fact that the chart was not used as a tool, because of its legal status. Conclusions: Redesigns of the chart should take these hidden aspects into account and any interventions in anaesthesia practice shouldn’t be based in a purely engineering approach.
Keywords
anaesthesia, cognitive ergonomics, cognitive engineering, ethnography, anaesthesia chart, distributed cognition
Introduction
The act of giving of anaesthesia is a complex, event driven task with tight constraints and adverse consequences (Gaba, 1994). The goal of the anaesthesiologist isn’t to simply “put the patient to sleep”. The anaesthesiologist is also responsible of ensuring the patient’s wellbeing and optimal surgical conditions (adequate muscle relaxation etc.). Furthermore, the anaesthesiologist does not work alone, but is a part of the anaesthesiology team and has to cooperate closely with the surgical staff and nurses.
The complexity of the anaesthesiologist’s task rises constantly and one of the contributing factors has been the very technology that attempts to reduce it: for example the number of displays, alarms and waveforms on a top of the range monitor has risen approximately from 4 in 1970 to 23 in 2000 (Beatty, 2000). This results in information overload that the anaesthesiologist is uncapable of handling (Weiss et al., 2000). This results in human error being an issue in anaesthesia practice, as it is associated with more than 80% of critical anaesthesia incidents (Cooper, Newbower, Long, & McPeek, 1978).
There has been extensive research on the domain, focusing on various aspects of the anaesthesiologist’s practice: classical ergonomics approaches (Held, Stahl, Guggenbuehl, & Krueger, 1996), studies on human error (Marmaras & Lykogianni, 1994; Marmaras & Maliagrou, 1996), cognitive engineering (Cook, Woods, & McDonald, 1991; De Keyser & Nyssen, 1993) e.a.
There also have been efforts to develop software to support the anaesthesiologist during the operation. Such software either follows an Expert System (Mora, Passariello, Carrault, & Pichon, 1993) or an Ecological Interface approach through integrating the monitor’s displays. Expert Systems belong to the GOFAI (Good Old Fashioned Artificial Intelligence, (Haugeland, 1985)) tradition of replacing rather than supporting the expert practitioner. But such systems don’t take enough of the context into account, so their suggestions tend to be irrelevant for the situation at hand (Dreyfus, 1972). Another approach are integrated or “ecological” displays (Zhang et al., 2002), which aim at integrating data into rich, complex units that could lead to improved performance of the actor. This approach has shown promise but nevertheless focuses on a limited part of the anaesthesiologist’s practice.
The present study deals with the anaesthesia chart which is a paper form constituted by a grid, where during the operation the anaesthesiologist records the timeline of the patient’s physiological parameters during the operation (blood pressure, pulse etc), and data fields where he can record the drugs administered as well as information about the patient (name, age, weight, ASA rating) which was gathered during the preoperative assessment.
The goal of our research was to study the subtleties of the anaesthesiologist’s practice in order to design a replacement for the anaesthesia chart. Simultaneously, we wanted to exploit the opportunities offered by the digitization of the chart so that it would be able to support the anaesthesiologist’s tasks while removing the burden of manually recording the progression of the patient’s vital signs. What triggered our research was the initial assumption that the anaesthesia chart was an artefact which represented the crystallization of years of practice and was used by the practitioner as a cognitive tool. In fact, in a preliminary interview an anaesthesiologist claimed that he couldn’t picture his work without it. There is also a growing tendency to introduce information technology into all areas of the Operating Theatre and integrate them through a hospital-wide information system, which demands the digitisation of the patient record and the anaesthesia chart. The Actant-Network’s motivation lies in the rationalisation of the hospital’s management, especially regarding its relationship with insurance corporations; sometimes the implicit goal of such systems is to limit the power and autonomy of medical staff (Berg & Bowker, 1997).
Method
We present here the approach used in our study of the anaesthesiologist’s work in view of designing a replacement for the anaesthesia chart (Papantoniou & Marmaras, 2004, 2005). To analyse the anaesthesiologist’s work, we used a mixture of ergonomic work analysis and ethnography, using a flat modelling method to represent the domain. More specifically, we focused on the anaesthesiologists’ interactions with their environment, their mediated treatment of the patient and especially their use of artefacts like the anaesthesia chart.
Our research was conducted between November 2002-May 2003, and involved two public Greek hospitals and 20 anaesthesiologists. The two hospitals specialized in different areas: one was an oncology hospital and the other a children’s hospital. Of the 20 anaesthesiologists, 13 were senior and 7 residents. Nine of the senior anaesthesiologists had 15 or more years of experience. All the residents were past their 3rd (of a total of 5) year of residency. All of the nurses involved were fairly experienced (over 10 years) except one who was on her first year in the anaesthesiology department. We conducted over 100hrs of field observation in the Operating Theatre (OT). The duration of the operations assisted ranged from 30min (tonsillectomy) to more than 6 hours (colectomy).
The number of people in the theatre depended on the type of operation and ranged from five (a surgeon, a nurse, an anaesthesiologist and an anaesthesiology nurse) to more than ten. The typical anaesthesia team in the first hospital consisted of a senior anaesthesiologist, a resident and an anaesthesia nurse, while in the second it consisted of a senior anaesthesiologist and an anaesthesia nurse (there were no residents).
The main part of the study was comprised by the field observations in the OT which were complimented with self-confrontation interviews. The researchers had negotiated their entry into the OT with the anaesthesiology department and the head nurse; the rest of the staff learned of our presence the moment they entered the OT. Sometimes we explained the aim of our research, but on some occasions the anaesthesiologist found it more appropriate to introduce the researcher as a doctor doing research for his PhD as she thought that “this man would never accept non-medical staff to be present during his work!” After the initial observations the researcher was known as the “researcher” and was gradually accepted by the community.
We had to rely on written notes taken during the operation and photocopies of the completed anaesthesia chart. We also performed self-confrontation interviews (Theureau, 2002) with the anaesthesiologists whenever possible (usually shortly after the operation in the doctors’ lounge). Self-confrontation is a method where the actor – in this case the anaesthesiologist – is interviewed while he is watching a representation of his own actions. The goal is to capture pre-reflective aspects of practice, which would not be captured by a traditional interview. Ideally the actor confronts his actions on video, but we had to rely on the reconstruction made by the written notes and the completed anaesthesia chart. The anaesthesiologists objected to the idea of a video camera as they thought it was too obtrusive and feared it would cause reactions by the surgeons and nurses.
The collected data were processed and in the following days there was a follow-up discussion on some of the incidents involved. These interviews were done either with each member of the team individually and a few times all the members of the team were present. The notes were transcribed into a spreadsheet and categorized according to actor, type of action, artefact involved and procedure. Through the analysis, we discovered regularities in the team’s behaviour in the domain.
Initial Framing
To frame the anaesthesiologist’s worksystem we used the Pole A – Pole B continuum formalism. The Pole A – Pole B continuum (Marmaras & Nathanael, 2005; Nathanael, Marmaras, Papantoniou, & Zarboutis, 2002) is a formalism intended to help analysts in framing a system. Systems attracted by Pole A are heavily constrained by physical invariants, leaving little room for other constituent elements of the system to influence behaviour (e.g. power plants). The people in the system are like Simon’s ant on the beach (Simon, 1969): their behaviour can be predicted by studying the physical constraints of the system. On the other hand, in systems attracted to Pole B (e.g. office settings), the system is loosely coupled (Perrow, 1999), leaving other aspects of the system (e.g. dynamics of practice) to shape its behaviour.
Pole A systems are better modelled using externalist, hierarchical approaches as these are better suited in reducing the complicatedness of the observed system to manageable levels. Pole B systems on the other hand are better described using Internalist, flat approaches as the social element predominates.
After some hours of observations, we recognized that the studied work system can be considered to be attracted to Pole A. However, as the observations progressed we recognized some Pole B characteristics, especially during routine operations. More specifically, in our framing of the system we recognized that the system was in many ways tightly coupled, the reason being the delicate balance of the patient’s vital signs, the other being the tight coupling with the surgical team. During the operation, the pace is set by the surgical team, while the anaesthesiologist has a reactive function and tries to support the patient’s homeostasis. The surgeon initiates events to which the anaesthesiologist must react with an appropriate action, so in this sense one can see some similarities with a process control task (Xiao, 1994). Because of this and the fact that the system is inherently complex and has no slack, it can be recognized that it is attracted to Pole A, in that the constraint map of the system is almost entirely shaped by physical constraints and there is little opportunity for other elements of the system –e.g. practice– to emerge as determinants of its overall behaviour. However, during routine incidents, where the tolerance of the system is higher, the work system exhibits signs of Pole B, so practice emerges a determinant of the system’s behaviour. This is reinforced by the fact that anaesthesia is an open-loop process: according to Cooper (1987) 86% of anaesthesia cases involve unexpected events.
Episodes from Actual Practice
We will present and discuss episodes and some findings of our analysis that show aspects of the anaesthesiologist’s practice that would be difficult, if not impossible to be captured by a positivist approach and modelled by a typical hierarchical method.
1st Episode
During a colectomy –a lengthy operation– the senior anaesthesiologist was ready to administer muscle relaxant, when the nurse interrupted him:
Table 1: Excerpt from a dialogue in the OT
|
(is ready to administer muscle relaxant) |
Nurse: |
-This syringe is faulty!! |
Nurse: |
(takes the anaesthesiologist a bit farther from the surgeon) |
Nurse: |
(silently) -We administered 5 minutes ago! |
In the above incident, the anaesthesia team’s mutual awareness (Hutchins, 1995) emerged: the nurse, who at the time was preparing drugs for the next incident, noticed which drug the anaesthesiologist took from the tray (muscle relaxant). Because she had been observing the operation’s progression –although it is not part of her typical tasks–, she remembered that they had administered muscle relaxant five minutes ago, and so averted the anaesthesiologist from administering a dangerous double dose.
The anaesthesia team’s distributed memory and the members’ mutual awareness create a redundancy of information which reduces the system’s brittleness during critical incidents. In fact, each anaesthesiologist takes breaks during the maintenance phase, and goes to other operating theatres to watch and discuss with colleagues, leaving the other anaesthesiologist or the anaesthesia nurse in charge. This incident also shows that when Pole A systems are not in a crisis, there is an opportunity for the softer elements of the system (Checkland, 1981) to influence behaviour, as the nurse’s attempt to cover the anaesthesiologist’s slip shows. Such behaviour is not uncommon and has been observed in other medical settings too (Hughes, 1988). In another similar incident, which happened during a crisis –where the system has no slack and its behaviour is typical of Pole A–, the nurse just corrected the anaesthesiologist –there was, as another anaesthesiologist commented, “no time for niceties”.
Cooperation between surgeon and anaesthesiologist is essential for the successful functioning of the system. Surgeon and anaesthesiologist work as a team rather than two independent actors, because they act towards the same object. This has positive results–mutual awareness between the two teams–, but can also lead to conflicts.
In many cases the anaesthesiologist knows beforehand, or is informed by the surgeon, that in a particular point of the operation the surgical team will cause a major change in the patient’s physiological characteristics (pulse drop, blood loss etc.). As an example, during a caesium therapy, the anaesthesiologist knows that the administration of caesium causes a minor bradycardia, and because of this he has an atropine injection ready and observes the monitor readings closely. As soon as there is a drop in the patient’s pulse, he administers atropine.
2nd Episode
In another incident the anaesthesiologist negotiated with the surgeon the pace of the procedure so that he would be able to perform better.
Table 2: Excerpt from the 2nd Episode
|
-How long do you think it will last? |
Surgeon: |
-Uhmmm... 1-1.5 hour... |
Anaesth: |
-Yes. In the first 15-20min SLOW, so that I will be able to gather the blood… |
Surgeon: |
-You don’t want me to step on it… OK |
But even in such systems, where the higher level object is common –the well-being of the patient– the lower level objects differ: the doctor is concerned with repairing the damage at a structural level, while the anaesthesiologist is concerned with the patient’s homeostasis. This may lead to negotiations as above, or to conflict, when the surgeon feels the anaesthesiologist is obstructing the task at hand, or when the anaesthesiologist perceives the surgeon’s actions as dangerous for the patient.
3rd Episode
In this incident, the anaesthesiology nurse was the only member of the team present in the OT. There was no resident anaesthesiologist and the senior anaesthesiologist was in the recovery room and then in another OT to help with the induction of a difficult case. Because of this the anaesthesia chart was completed in regular intervals (5 times in an hour). Every time the nurse did a recordable action, it was on the chart. At some point the patient’s pulse dropped. The nurse noticed it on the monitor, while she was preparing drugs for the next patient.
While the anaesthesia chart is supposed to be completed in regular intervals (5-20min based on the grid provided by the anaesthesia chart), in actual practice it is not always the case. Depending on the member of the team that undertakes the completion of the chart we observed:
-
Complete and meticulous completion
-
Larger intervals between completion than those dictated by the grid
-
Post-operative completion
Meticulous completion was seldom observed. It was observed when the person responsible was positioned low in the team’s hierarchy and as a result was more likely to be checked upon. Almost all of the residents were meticulous in their completion, as well as the younger nurses.
On the other hand, senior anaesthesiologists and experienced nurses did not record the progression of the patient’s vital signs as often as they should, but they tended to record their own actions (e.g. administering drugs).
Table 3: Mean time between gazes on the anaesthesia chart
|
8min |
Resident Anaesthesiologists |
6min |
Senior Anaesthesiologists |
20min |
Post-operative completion of the anaesthesia chart is a sign that the diagram was not used as a tool by the anaesthesiologist.
On another incident the patient exhibited signs of bradycardia. The anaesthesia team managed to bring him to a normal state. Toward the end of the operation, the anaesthesiologist started completing the anaesthesia chart. Instead of an accurate picture of the situation, the anaesthesiologist wrote “nominal” values on the chart.
Table 4: Flow of a typical operation (white spaces designate absence from the OT)
Most of the small variations of the patient’s state that take place during the operation are not recorded on the chart. In order to explain this behaviour we made the hypothesis that there is a predominance of the chart’s legal being over its original use. This is due to the fact that the chart can be used as evidence in a trial for medical malpractice. For example, in the U.S. in the case of Vuletich vs. Bolgla (85 Ill. App. 3d, 810, 407 N.E. 2d 566, Illinois, 1980), the theory of the patient’s lawyer on the incident was based on the fact that the anaesthesiologist did not adequately monitor the patient’s state. As evidence he used the fact that the anaesthesia chart was not completed correctly. In another case (Kearl v Board of Medical Quality Assurance (189 Cal. App. 3d, 1040, 236 Cal. Rptr. 526, 1986)) there was a question as to whether the anaesthesiologist was continually monitoring the patient’s vital signs. The anaesthesiologist allegated that he monitored every 5min, but recorder only every 15mn, because the chart’s grid had 15min intervals. The difference is important, as only 3-4min were required for irreversible brain damage.
For this reason we found that many anaesthesiologists’ goal–and especially the seniors–was that the chart should be completed so as to seem “normal”. In order to achieve this, many incidents were never recorded and the chart was completed post-operatively. The second reason is that from the anaesthesiologist’s view (but not from the system’s view) the anaesthesia chart is another object that requires attention, and does not offer any value, especially in short operations.
Although we discovered numerous instances of non-systematic use of the chart, it was difficult to discuss this with the anaesthesiologists. Only after many hours of participating in their community, in corridors and the smoking room, were we able to draw a statement that “some anaesthesiologists do this because they have nothing to gain from completing the chart and the act itself can be the cause of trouble.” As a tool, the anaesthesia chart is in a precarious position. Its users are afraid of using it when they need it the most: during crises.
Discussion
The episodes above show some aspects of anaesthesia practice that definitely shape the system’s behaviour, and have been captured adopting an ethnographic approach and using flat modelling, permitting to easily alter the shaping of the system as a Pole A or Pole B system, according to the observed behaviours. These are aspects that can directly and deeply influence design: e.g. the first episode shows that knowledge of the anaesthesia procedure and its present state doesn’t lie exclusively in the mind of the anaesthesiologist, but rather is distributed between team members and artefacts – so it wouldn’t be wise to base the new design around a device that only the anaesthesiologist himself will be able to update (i.e. a personal PDA-like device).
Furthermore, analyzing such a system using a typical engineering approach may lead to solving the wrong problem. As our research showed, the anaesthesia chart’s legal status has predominance over its status as a tool for the anaesthesiologist. This fact affected practice more than any of the factors that can be found with a traditional analysis regarding functionality or usability, as it affects the anaesthesia chart’s goal. If the system ignores this fact, it is very likely to be sabotaged by the staff, a situation that has emerged in other medical settings where new technology limits the autonomy of medical staff (Nathanael & Marmaras, 2005).
We advocate that in order to draw near an accurate analysis of the system, a multimethodological (Mingers & Brocklesby, 1996) approach is needed. This is a pragmatic approach where theories can be viewed as tools (Marmaras & Nathanael, 2005) or lenses, where each theory enables the analyst to focus on specific aspects of the system, while obscuring others, creating in effect a new functional space in which the analyst operates.
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latest news
17/09/2007
New blog: Ergoduction (in greek)
17/09/2007
Now work for HALCOR as a Development and Planning Engineer.
7/08/2007
Paper "Hidden Aspects of the Anaesthesia Chart" accepted by Journal of Clinical Monitoring and Computing
