Table 1

Experimental multi-element HFE intervention

System featureSpecific deficiencies identified in baseline system implementationExperimental intervention implementedHFE basis for intervention
Physical/human-machine HFE (system hardware+accessibility)
Alarm system hardware (alarm audibility)Alarm speakers muted or non-functional• Repositioning of speakers to distributed telemetry display locations • Adjustment of alarm volumes for audible, less obtrusive notification• Hardware assessment • Real-time observation • Simulation observation • End-user Web survey and discussions
Alarm system hardware (alarm visibility)Telemetry displays located in peripheral areas (eg, hallways, spaces for ED interpreting services)• Repositioning of central telemetry displays to physician stations • Installation of distributed telemetry large-screen displays at nurse stations (with reduced emphasis/reliance solely on audible alarms)• Hardware assessment • Real-time observation • Simulation observation • End-user Web survey and discussions
System input interfaceTraditional keyboard and mouse input devices missing, also suboptimal for limited workspace• Placement of touchpad input devices at physician station telemetry displays and at nursing stations for intuitive interaction• Hardware assessment • Usability assessment • End-user discussions
Cognitive/Human-Software HFE (System Informational Relevance+Utility)
Clinical relevancePoor signal:noise ratio, with excessive false alarms (anticipatory and immediate)21 resulting in ‘alarm fatigue’• Alarm parameter adjustment to reduce false alarms, ie,  ‘Red’ alarms only for: – Asystole >4 s – Bradycardia <40 bpm – Tachycardia >130 bpm – (VF) or (VT>100 bpm)  ‘Yellow’ alarms for: – NSVT – R-on-T PVC – SVT >180 bpm – Ventricular rhythm >14 PVCs  Additional vital sign alarms: – SBP >200 mm Hg – SBP <90 mm Hg – SpO2 <89% – Removal of all RR alarms (eg, apnoea) • Two-room CareGroup pairing• Real-time observation • End-user Web survey and iterative discussions for participatory design • Institutional expert input+guidance with modified Delphi process
General utilityLow yield of system access for clinical providers• System integration into nurse charting informational workflow• End-user Web survey, discussions • RN observations
Organisational/human-organisation HFE (system maintenance+user base)
System maintenanceSystem PC components in disrepair (disconnected, physically distressed and/or non-booting PC's)• Repositioning and updating of system PC components in separate, secluded spaces • Coordination of institutional infra-structure for routine maintenance• Hardware assessment • Institutional expert input • 5S principles (sort, straighten, sweep, standardise, sustain)
User awarenessWidespread knowledge deficit of system presence, availability and features• Announcement of study conduct and intervention at ED personnel meetings • Study simulation sessions• Real-time observation • Simulation observation • End-user Web survey and discussions
User familiarityWidespread knowledge deficit of system operation• Group in-servicing and on-shift in-servicing of ED personnel• Real-time observation • End-user discussions
  • ED, emergency department; HFE, human factors engineering; NSVT, non-sustained ventricular tachycardia; PVC, premature ventricular contraction; RR, respiratory rate; SBP, systolic blood pressure; SpO2, oxygen saturation (pulse oximetry); SVT, supraventricular tachycardia; VF, ventricular fibrillation; VT, ventricular tachycardia.