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Use of in situ simulation and human factors engineering to assess and improve emergency department clinical systems for timely telemetry-based detection of life-threatening arrhythmias
  1. Leo Kobayashi1,
  2. Ramakrishna Parchuri2,
  3. Fenwick G Gardiner3,
  4. Gino A Paolucci3,
  5. Nicole M Tomaselli3,
  6. Rakan S Al-Rasheed4,5,
  7. Karina S Bertsch3,
  8. Jeffrey Devine3,
  9. Robert M Boss3,
  10. Frantz J Gibbs1,
  11. Eric Goldlust1,
  12. James E Monti1,
  13. Brian O'Hearn3,
  14. David C Portelli1,
  15. Nathan A Siegel1,
  16. David Hemendinger6,
  17. Gregory D Jay1,4,7
  1. 1Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
  2. 2Department of Biomedical Engineering, Rhode Island Hospital, Providence, Rhode Island, USA
  3. 3Emergency Department, Rhode Island Hospital, Providence, Rhode Island, USA
  4. 4Rhode Island Hospital Medical Simulation Center, Providence, Rhode Island, USA
  5. 5King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia
  6. 6Information Services, Lifespan, Providence, Rhode Island, USA
  7. 7School of Engineering, Brown University, Providence, Rhode Island, USA
  1. Correspondence to Dr Leo Kobayashi, Department of Emergency Medicine, Alpert Medical School of Brown University, Rhode Island Hospital Medical Simulation Center, Suite 106, Coro-West Building, 1 Hoppin Street, Providence, RI 02903, USA; LKobayashi{at}


Background and objectives Medical simulation and human factors engineering (HFE) may help investigate and improve clinical telemetry systems. Investigators sought to (1) determine the baseline performance characteristics of an Emergency Department (ED) telemetry system implementation at detecting simulated arrhythmias and (2) improve system performance through HFE-based intervention.

Methods The prospective study was conducted in a regional referral ED over three 2-week periods from 2010 to 2012. Subjects were clinical providers working at the time of unannounced simulation sessions. Three-minute episodes of sinus bradycardia (SB) and of ventricular tachycardia (VT) were simulated. An experimental HFE-based multi-element intervention was developed to (1) improve system accessibility, (2) increase system relevance and utility for ED clinical practice and (3) establish organisational processes for system maintenance and user base cultivation. The primary outcome variable was overall simulated arrhythmia detection. Pre-intervention system characterisation, post-intervention end-user feedback and real-world correlates of system performance were secondary outcome measures.

Results Baseline HFE assessment revealed limited accessibility, suboptimal usability, poor utility and general neglect of the telemetry system; one simulated VT episode (5%) was detected during 20 pre-intervention sessions. Systems testing during intervention implementation recorded detection of 4 out of 10 arrhythmia simulations (p=0.03). Twenty post-intervention sessions revealed more VT detections (8 of 10) than SB detections (3 of 10) for a 55% overall simulated arrhythmia detection rate (p=0.001).

Conclusions Experimental investigations helped reveal and mitigate weaknesses in an ED clinical telemetry system implementation. In situ simulation and HFE methodologies can facilitate the assessment and abatement of patient safety hazards in healthcare environments.

  • Emergency department
  • Human factors
  • Information technology
  • Patient safety
  • Simulation

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