Human Factors and Ergonomics of Prehospital Emergency Care

Joseph R. Keebler, Elizabeth H. Lazzara, Paul Misasi, Joseph R. Keebler, Elizabeth H. Lazzara, Paul Misasi

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781315280158
• Edition: 1
• Topic: Business
• Subtopic: Industria dei servizi
• Index: Business

This book provides an introduction to the field of human factors for individuals who are involved in the delivery and/or improvement of prehospital emergency care and describes opportunities to advance the practical application of human factors research in this critical domain. Relevant theories of human performance, including systems engineering principles, teamwork, training, and decision making are reviewed in light of the needs of current day prehospital emergency care. The primary focus is to expand awareness human factors and outlay the potential for novel and more effective solutions to the issues facing prehospital care and its practitioners.

1 Introduction to Human Factors and Ergonomics of Emergency Medical Services

Paul Misasi and Joseph R. Keebler

CONTENTS

What Is Human Factors?

What Human Factors Is Not

Human Factors Has Already Made a Difference in EMS

A Word about Human Error

References

Human error in medicine, and the adverse events that may follow, are problems of psychology and engineering, not of medicine.

John W. Senders

Medical Devices, Medical Errors, & Medical
Accidents, in Human Error in Medicine, 1994

The delivery of emergency medical services (EMS), or what we will interchangeably refer to as prehospital medicine (arguably a more accurate moniker^*), is a complex enterprise that exists at the confluence of medicine, public safety, public health, and transportation—both air and ground (Shrader, 2015). All but a handful of decades old, it continues to seek its place among the professional domains, especially in the United States. EMS agencies struggle for recognition as a distinct but critical element of the public᾿s safety net and gateway into the healthcare system. Although EMS is generally well respected, it is often forgotten and receives substantially less funding and recognition than its law enforcement and fire suppression counterparts. In 2005, a New York University report investigating the preparedness of the United States᾿ first responders revealed that EMS agencies (apart from fire departments) received less than 4% of federal monies made available in the aftermath of the devastating terrorist attacks of September 11, 2001. Unfortunately, this is a reality that many EMS providers and managers have become all too familiar with. However, EMS professionals continue to forge ahead, and demonstrable progress has been made elevating the ­professionalism of the domain and the delivery of the service. As we write this chapter, a number of factors are beginning to converge that we believe will only increase the importance that EMS providers, managers, system designers, and leaders place on quality improvement, resilience, safety, and sustainability. Likewise, human factors, systems and industrial engineers, ergonomists, and patient safety researchers will find new and largely untapped opportunities that have been overlooked in the past.

*We recognize also that out-of-hospital medicine would probably be the best fit for the profession; but in aligning this book᾿s vernacular, we chose the former.

Although certainly not an exhaustive list, we believe four interacting influences are worth mentioning as they bear on the importance of incorporating human factors in prehospital medicine and its systems of delivery. First, a significant leap in the industrialization of EMS was made in the 1980s to the 1990s through the work of Jack Stout at the University of Oklahoma᾿s Center for Economic Management and Research, funded by the Kerr Foundation (Shrader, 2015). Since then, agencies have reconsidered the constraints and the opportunities afforded by system design with an economic lens. Stout᾿s work identified the unique operating and market characteristics of ambulance services that influence the substantial variability in system cost compared to the quality of service, revealing critical elements of system design and operational strategies to optimize the efficiency and the effectiveness of service delivery models (Stout, 1994).

Secondly, the work of Edward Deming and others in the field of quality management has influenced general management theories and has proven the importance of systems thinking as it pertains to business processes and their design and improvement. Perla, Provost, and Parry (2013, p. 172) reviewed how the four tenets of Deming᾿s System of Profound Knowledge are critical to healthcare᾿s ability to make improvements:

• Appreciation for a system: A focus on how the parts of a process relate to one another to create a system with a specific aim
• Understanding variation: A distinction between variation that is an inherent part of the process and variation that is not typically part of the process or cause system
• Theory of knowledge: A concern for how people᾿s view of what meaningful knowledge is impacts their learning and decision-making (epistemology)
• Psychology: Understanding how the interpersonal and social structures impact performance of a system or a process

As will become evident throughout this chapter and this book, there is a substantial overlap between the sciences of improvement and human factors across all four of these areas.

Thirdly, in 2012, the American Board of Medical Specialties approved EMS medicine as an official subspecialty of medicine, recognizing the unique environment, the distinct body of knowledge and skills necessary, and the constraints of care delivery, and the American Council for Graduate Medical Education subsequently began awarding fellowships in EMS.

Lastly and arguably the most influential in the United States, the Affordable Care Act of 2010 has begun to remodel payment incentives from a volume-based, fee-for-service standard to a quality of care paradigm. Although EMS has not been explicitly targeted by payers for a demonstration of value and quality as a contingency for reimbursement, leaders in the industry realize that the clock is ticking. Efforts to prepare for this eventuality are currently underway with an initiative known as EMS Compass, funded by the National Highway Traffic Safety Administration and administered by the National Association of State EMS Officials. One goal of EMS Compass is to develop the practical metrics by which EMS agencies can demonstrate quality and value before those metrics are developed and imposed by external agencies with less interest in their feasibility (National Association of State EMS Officials, 2015).

To summarize, as EMS rightfully aligns itself more closely with healthcare, the Affordable Care Act has communicated and codified that it is imperative to demonstrate quality and value of service; EMS Compass efforts that are underway will assist with the identification of what requires our clinical and managerial attentions, and through a grounded understanding of human factors and systems engineering, we can learn how to intervene in meaningful ways that do not rely on perfect knowledge, perfect skill, or perfect performance from providers at the “sharp end” to achieve improvement.

Ambulance services throughout Europe and Australia have been incorporating the analysis and the design tenets of physical ergonomics for some time and are leading the way in improving the physical safety of providers; meanwhile, their American counterparts are just beginning to update the decades-old standards and specifications for ambulance design to improve safety (see the study by the Commission on Accreditation of Ambulance Services, 2016). We all however, remain a long way from our goal. Maguire et al. (2014) recently published the findings of an Australian investigation, citing that the risk of serious occupational injury for paramedics was seven times higher than the national average and that the fatality rate was six times higher than the national average. Twelve years earlier, Maguire et al. (2002) published findings that the occupational fatality rate for paramedics in the United States was two and a half times higher than the national average.

The scientific investigation of the cognitive ergonomics of prehospital care has only begun to scratch the surface. Since the Institute of Medicine᾿s report To Err Is Human (Kohn, Corrigan, and Donaldson, 1999) was released 17 years ago, the science of human factors has increasingly focused on applications in the medical domain—covering topics such as device design and user interface, medication safety, teamwork, effects of stress and fatigue, workflow, cognitive artifacts, expertise, social and organizational cultures, judgment and decision-making—all with the aim of understanding their effects on the safety and the quality of medical care. Efforts have been made to translate the practices developed in other complex sociotechnical domains such as aviation, but prehospital medicine has not gained the same amount of attention from the research community. Thus, this book begins as an endeavor to fill a niche of applying the science of human factors and ergonomics (HF/E) to prehospital medicine, with a hope that it will not only begin an important and continuing conversation between the two disciplines but also open the eyes of everyday practitioners, managers, EMS physicians, and leaders to a science that can aid them in their daily performance of work tasks, preserve and protect their livelihood, help save the lives of their patients, facilitate optimal performance as clinicians, and optimize processes to achieve organizational goals.

Modern healthcare has been called the most complex domain of work known to humans (Gluck, 2008), a statement that was referring to healthcare delivered in controlled settings (i.e., hospitals). EMS providers face these complexities and the additional factors of delivering healthcare in a mobile, volatile, unpredictable, and unforgiving environment. As such, they arguably have one of the most cognitively and physically demanding jobs in healthcare. It is medicine on the front lines, sometimes literally in the trenches. We believe that a book such as this will enhance the current best practices and the methods by which they are achieved. It is our hope that this work leads to new efforts and relationships between HF/E and EMS. With the eventual move of EMS to the Department of Health and Human Services in the United States, this book could help lay the groundwork for a long-lasting relationship between the two fields. This chapter will provide a high-level overview of what HF/E is, what it is not, and how it can and has been applied successfully.

WHAT IS HUMAN FACTORS?

HF/E is a broad, interdisciplinary science based on psychology and engineering that deals with the interface between humans and their work systems. Born out of necessity during World War II,^* it integrates knowledge and practice from multiple disciplines, including but not limited to computer science, organizational management, cognitive and social science, ergonomics, engineering, and industrial design (Wickens et al., 2004, 2013). The goal of HF/E is to make systems safe, reliable, intuitive, and supportive of the human operator by enhancing their work experience and optimizing performance (Russ et al., 2013). HF/E science takes a multilevel approach that focuses on individuals, teams, tasks, tools, systems, and organizations to best understand the complexity of the work system. The term ergonomics in a pure, holistic sense is defined as the study of work that is broadly inclusive of how the human mind and body interact with information and tools in the environment to achieve the goals of work (Wickens et al., 2013). While this definition is more commonly understood among our European and Australian counterparts, in colloquial American parlance, the term more commonly refers to the design of physical environments, tools, and devices (e.g., chairs, grips, and seats) in a more anthropometric^† sense. There are a number of terms that have become common in order to capture the nuances of specialized HF/E practice as the built environment becomes more complex and technical, just as there are various and increasing levels of specialization in medicine (e.g., physician → orthopedist → hand surgeon; physician → internist → cardiologist). Some examples of these terms include cognitive ergonomics, cognitive engineering, cognitive systems engineering, macroergonomics, usability, and others that are generally encompassed by the umbrella term of human factors (Lee and Kirlik, 2013). However, in HF/E, there is a substantial overlap among subspecialties, and they are not as conveniently distinct as organ systems in the human body or necessarily divided in terms of skill sets as they are in medicine. HF/E is considered a science because its practitioners have usually earned a PhD that requires the study and the application of rigorous scientific methods and statistical evaluation for describing a phenomenon with a high degree of reliability and validity, beyond what may be attributable to chance.

*For a review of the historical development of human factors, see the study by Meister (1999).

^†Anthropometry is the science that evaluates the metrics of human sizes, forms, and functional capabilities (Centers for Disease Control and Prevention, 2016).

Finally, the phrase human factors approach is commonly used to mean and is arguably synonymous with the phrase systems approach, in the sense that both seek to design systems that support human performance (while accounting for human limitations) and are resilient to perturbations or unanticipated events (Dekker, 2011).

Russ et al. (2013, p. 802) describe that there are two goals for the HF/E application in medicine: “1) support the cognitive and physical work of healthcare professionals and 2) promote high quality, safe care for patients.” In relation to prehospital care, HF/E can aid providers, managers, and leaders by enhancing the design of their medication preparations and packaging, tools, gear, ambulances, communication systems, teamwork (from the dyadic, two-person interaction to the much larger multiteam systems), organizational policies, and general work practices. This book is organized to focus on the aspects of the individual, the team, and the organization to holistically capture the delivery of prehospital medicine.

WHAT HUMAN FACTORS IS NOT

When someone says that they are a physician, they have communicated to you that they have a professional doctorate degree in medicine (MD for allopathic physicians; DO for osteopathic physicians), which means that they have obtained the broad knowledge base about the physiology, the pathophysiology, and the treatment regimens of the human body that all physicians receive; what the term physician has not communicated is their particular specialty or which branch of medicine they have chosen to focus their practice on (e.g., family medicine, orthopedics, etc.). In the same manner, when someone indicates that they have a doctorate in psychology, it would be incorrect to assume that they are a clinical psychologist who sees patients in an office or a hospital performing talk therapy. This is a leap that is analogous to assuming that al...