Improving Situational Awareness During Interfacility Transport Using a Transport Monitoring and Communication Application: A Simulation-Based Pilot Study

Abstract

Objectives:

To evaluate the impact of using a simulated teletransport application compared with ad hoc phone calls between medical control physicians (MCP) and transport teams on situational awareness and communication during neonatal interfacility transports.

Methods:

In this pilot study, MCPs and pediatric critical care transport teams (PCCT) participated in simulated neonatal transports with or without a simulated transport monitoring and communication (T-MAC) application. Situational awareness (perception, the recognition of the patient’s status; comprehension, the understanding of the significance of patient’s status; and projection, anticipation of what the patient’s status will likely become) and the overall duration of communication was measured and compared between and within groups.

Results:

Thirty-three subjects (20 MCP, 13 PCCT) participated in 52 simulations. MCPs had higher overall situational awareness scores with use of the T-MAC app compared with ad hoc phone calls with increased mean perception (98%, T-MAC versus 79%, no T-MAC, P = 0.003) and projection (53%, T-MAC versus 40%, no T-MAC, P = 0.004) scores before a patient event (sudden adverse change to patient status); and increased perception (83%, T-MAC versus 64%, no T-MAC, P = 0.03); comprehension (68%, T-MAC versus 48%, no T-MAC, P = 0.04); and projection (58%, T-MAC versus 30%, no T-MAC, P = 0001) scores after the event. PCCTs had higher mean perception (98%, T-MAC versus 81%, no T-MAC, P = 0.02) and projection (54%, T-MAC versus 45% no T-MAC) scores before the event. The median duration of call times decreased for adverse events (125, IQR: 45s, T-MAC versus 140, IQR: 70s, no T-MAC, P = 0.046).

Conclusions:

In this simulated setting, the use of a specially designed teletransport app for neonatal interfacility transports improved situational awareness and increased the efficiency of communication for transport team stakeholders. There was greater benefit in improving situational awareness for the MCPs than for PCCT members. The development and use of a T-MAC application warrants further investigation.

Neonatal interfacility transport is a complicated and risky process with adverse events occurring in up to 70% of critical care ambulance transports even with a highly trained team.^1–3 Two-thirds of avoidable adverse events are rooted in human factors such as inaccurate or incomplete information sharing between teams and facilities.⁴ Situational awareness is crucial to optimize patient safety on transports.⁵ Communication failures can impair situational awareness, impacting prioritization, assessment of urgency, appropriateness of transfer, and equipment selection.⁶ Improved communication and situational awareness during transport may lead to fewer errors and support clinical decision-making.⁷

Prior studies with medical control physicians (MCPs), pediatric critical care transport (PCCT) team members, and parents of transported patients identified additional information that would be beneficial to improve team communication and patient safety during neonatal transports.^8,9 In a teletransport study by Curfman et al,¹⁰ failures occurred in 17% of transports due to human factors such as difficulty in opening the application, logging in, or using the equipment. Telemedicine tools are developed to fill this need; however, few neonatal telemedicine transport tools have been piloted in real world settings and recent studies suggest that there are gaps in the usability and features of current tools.^10–12

To explore the potential improvements of teletransport for neonates, a simulated mobile application called the transport monitoring and communication (T-MAC) application was designed with input from transport stakeholders for use during neonatal interfacility transport. Key features included clinical information, location, live-video streams, messaging, and note-taking functionalities.⁸ This study compared the impact of using the T-MAC application (intervention group) with the current standard practice of communication using ad hoc phone calls between MCPs and PCCT team members on situational awareness and communication in a simulated transport environment. We hypothesized that the use of the T-MAC application would be associated with improved situational awareness compared with phone communication alone.

METHODS

Study Design

This was a between-subjects study using a convenience sample of MCPs and PCCT team members.

Study Participants

MCPs and PCCT team members were invited by email to participate in the study. Only those who volunteered for this pilot study were included.

Study Setting

The study was conducted in a regional referral children’s hospital with a dedicated PCCT team or in a level IV neonatal intensive care unit. The MCP arm of the study was conducted in an office or a small conference room. In a separate room, a neonatal manikin was placed in an uncovered nontransport neonatal incubator with an embedded participant serving as the PCCT member. A camera for streaming video of the manikin was placed on top of the incubator. The study with PCCT was conducted separately with PCCT members seated around a transport incubator containing a neonatal manikin and a remotely located embedded participant serving as the MCP. The participants were seated in an orientation mimicking the seating in the ambulance with the transport nurse seated opposite the center of the incubator and the respiratory therapist seated at the end of the incubator by the feet of the patient. If an emergency medical technician (EMT) participated, they stood nearby. The EKG and invasive blood pressure probes were placed on the manikin in positions that approximated reality. The video streaming camera was placed on top of the incubator. A tablet running a patient monitor simulator app (SimMon, Castle+Andersen ApS, Denmark) was set in front of the inactive transport monitor. The simulated vital signs were controlled remotely by the facilitator running the same app on a separate device. The study was approved by the Institutional Review Board STUDY00008079.

Transport Monitoring and Communication Application

The T-MAC was developed in the Unity software platform (Unity3D). There were 2 versions for use by the MCP and PCCT teams. The features of the T-MAC used by the MCP included: real-time vitals, historical vital sign plots, patient location with estimated time of arrival, live-video stream of the patient, live-audio audio stream of patient, patient electronic medical record, streamlined voice communication with the PCCT, and note-taking (Fig. 1).

FIGURE 1.

Screenshots from MCP version of the simulated T-MAC application showing real-time video monitoring and ambulance location. BPM indicates beats per minute.

The PCCTs used an alternative T-MAC version that was adapted to their needs. It included all the same features of MCP version, except for live-audio streaming, with the following additions: streamlined voice communication with the receiving facility in addition to the MCP; text communication group chat; access to the device’s camera with a gallery; a button to signal to the T-MAC system that transport has begun; and a quick access button to a pediatric reference app already installed on the device.

Simulation Scenarios

Two neonatal transport scenarios featuring newborns with the neurological and surgical conditions: hypoxic ischemic encephalopathy (HIE) or neonatal brain injury and tracheoesophageal fistula (TEF) or congenital blockage of the trachea and esophagus, were developed by 2 neonatologists with MCP and simulation facilitator experience (Appendix 1, Supplemental Digital Content 1, http://links.lww.com/JPS/A746). In both scenarios, the simulated patient had a desaturation event to which the PCCT and MCP had to respond. Expected communication during the scenarios was modeled on standard communication patterns during interfacility neonatal transports in our network in which after a bedside assessment of the patient, the PCCT would call the MCP with an initial status of the patient and to receive care instructions. Once enroute, the PCCT would call the MCP if there had been a significant change to the patient’s status.

Simulation Setup

The simulations were conducted separately with MCPs and PCCT members using their versions of the T-MAC application. The HIE scenario used the T-MAC application and the TEF scenario used the standard practice (phone communication). Only one MCP was tested at a time while PCCT testing was done in groups with a transport nurse, respiratory therapist, and emergency medical technician (EMT; optional) to simulate realistic workflow. A remotely located trained embedded participant played the role of the MCP or PCCT member and was connected through a video conference session (Zoom, Zoom Communications, Inc., San Jose, CA) set up with a webcam placed to see and record the simulation. The embedded participant remained off camera.

Vital signs, ambulance position on the map, and estimated time of arrival were controlled by the simulation facilitator using a Bluetooth keyboard paired with the device running the T-MAC application for the MCPs. For the PCCT team, a control panel application on a separate device was used to trigger transitions simultaneously for all devices. The facilitator concealed their motions so in-room participants were unaware of impending changes in the simulated patients’ status. When vital sign changes were made, they occurred linearly over 20 seconds. All other changes occurred instantaneously. For the first 10 sessions in each group, the HIE scenario was presented first followed by the TEF scenario. For the subsequent 6 sessions, the TEF scenario was presented first, followed by the HIE scenario. All participants were given an orientation on the use of the T-MAC before the simulation. During the orientation, the facilitator prompted them to explore the app and its features by asking questions and giving them tasks. For MCPs, these involved finding the patient’s heart rate; historical SpO2 trends; the PCCT’s location; medications administered; opening the video and audio feeds; and calling the PCCT through the app. For the PCCT team, additional tasks included: taking and viewing a photo; opening the reference app; sending a chat message; and triggering departure.

Scenario Procedure

Before each scenario, participants were given a patient information sheet that included demographics, clinical diagnosis/reason for referral, referring site and provider, and a brief synopsis of the patient’s course. Scenarios began with a standard PCCT call from the patient’s bedside (see Fig. 2). During this call, the PCCT and MCP discussed the patient’s history and status and established a plan of care. Following this, the scenario was paused for the first situational awareness (SA) questions (Appendix 2, Supplemental Digital Content 2, http://links.lww.com/JPS/A747). After 2 minutes, a patient event resulting in decreasing oxygen saturation (SpO2) levels occurred. If a call was made by MCP or PCCT, the patient improved about 30 seconds into the call. If no calls were made within 2 minutes, or immediately after the call ended, if one was made within 2 minutes, the scenario is paused for the second set of SA questions. During the MCP scenarios, if the MCP did not call, the scenario was resumed with a call from the PCCT describing the adverse event. For both roles, one minute after the call and scenario pause, the facilitator prompted participants for an estimated time of arrival (ETA). The scenario then ended.

FIGURE 2.

Scenario procedure for medical control physician and transport team sessions.

MCP clinical guidance, other topics discussed on the call, and PCCT and MCP actions between calls were all left to the participant discretion. MCPs were encouraged to keep themselves occupied with other tasks during the scenario with suggestions including checking email or doing paperwork. If an EMT participated, they did not immediately provide care for the patient but were available to assist if requested by the respiratory therapist or transport nurse. They also could answer questions from the other participants. If the questions were ones that the EMT would realistically know, such as estimated time of arrival, this information was provided to the EMT by the simulation facilitator.

Surveys

The surveys on situational awareness measured 3 parameters: (1) perception, that is, the recognition of the patient’s status; (2) comprehension, that is, the understanding of the significance of patient’s status; and (3) projection, that is, anticipation of what the patient’s status will likely become. The survey was developed by the study team with expertise in human factors (PR), engineering (LL; PR; and MC) and neonatal medicine (RU and TS) with questions tailored to the simulation scenarios. There were 30 questions, 17 multiple-choice questions, 12 Likert-style questions and 1 open-ended response question. The perception questions focused on the participant’s knowledge of recent vital signs, medications administered and location, for example, “Please state your assessment of the last displayed oxygen saturation.” The comprehension questions focused on the participants understanding of the patient status, for example, “What is the current trajectory of the patient?” and the projection question focused on the next steps, for example, “Which action needs to be prioritized at this point?” (Appendix 2, Supplemental Digital Content 2, http://links.lww.com/JPS/A747). The demographics survey included questions on participants’ profession, level of experience and frequency of participation in neonatal interfacility transport. All surveys were completed on a tablet or phone using REDCap.¹³

Data Analysis

All statistical analyses were performed using R (version 4.1.1, R Foundation for Statistical Computing, Vienna, Austria). Demographic data were analyzed using descriptive statistics. Situational awareness scores were compared between session types (T-MAC and phone) using the paired t test to measure the effect of using T-MAC. The duration of calls for the MCP tests for 2 situations, the initial routine bedside call and the adverse event call, were also compared using the paired t test.

RESULTS

A total of 33 team members (20 MCPs and 13 PCCT) participated in 52 simulation scenarios (Table 1). PCCTs had a higher proportion of participants reporting 11 or more years of experience (62% PCCT versus 40% MCP). Both groups reported participating in at least one neonatal transport monthly on average.

TABLE 1.

Participant Demographics

Demographics, n = 33	Transport team members, n = 20 (%)	Medical control physicians, n = 13 (%)
Years of experience with neonatal transport (y)
<1	2 (15.4)	0
1-10	1 (7.7)	12 (60.0)
11-20	5 (38.5)	3 (15.0)
>20	3 (23.1)	5 (25.0)
Prefer not to answer	2 (15.4)	0
Age
20-35	1 (7.7)	2 (10.0)
36-50	6 (46.2)	13 (65.0)
51-65	4 (30.8)	5 (25.0)
Prefer not to answer	2 (15.4)	0
Average no. transports per month
<1 transports	0	3 (15.0)
1-10 transports	3 (15.4)	11 (25.0)
11-20 transports	7 (23.1)	3 (10.0)
>20 transports	1 (7.7)	3 (15.0)
Prefer not to answer	2 (15.4)	0
Role
Physician (MD)	0	20 (100)
Registered nurse (RN)	5 (38.5)	0
Respiratory therapist (RT)	4 (30.8)	0
Emergency medical technician (EMT)	1 (7.7)	0
Prefer not to answer	3 (23.1)	0
Sex
Female	8 (61.5)	15 (75.0)

In simulations with the T-MAC, MCPs demonstrated improved situational awareness, scoring higher on all 3 dimensions of situational awareness—perception; comprehension; and projection—before and after the event (P < 0.05; Fig. 3A). Comprehension before the event did not differ between the T-MAC and ad hoc phone scenarios.

FIGURE 3.

A, Medical control physician situational awareness scores with and without the use of T-MAC. B, Transport team situational awareness scores with and without the use of T-MAC.

PCCTs had higher mean perception scores (98%, T-MAC versus 81%, no T-MAC, P = 0.022) and projection scores (54%, T-MAC versus 45%, no T-MAC, P = 0.027) with a trend towards higher comprehension scores in the T-MAC scenarios (88%, T-MAC versus 62%, no T-MAC, P = 0.068) at the initial assessment (Fig. 3B).

MCP call times were shorter with T-MAC use (Fig. 4). The initial bedside call with T-MAC had a median of ∼140 seconds (IQR: 45 seconds) versus 160 seconds (IQR: 84 seconds) in the no T-MAC scenario (P = 0.337).

FIGURE 4.

Medical control physician call times with and without use of T-MAC.

Adverse event calls had a significantly shorter median duration for the MCP scenario with T-MAC app (125, IQR: 45 seconds, T-MAC versus 140, IQR: 70 seconds, no T-MAC, P = 0.046).

DISCUSSION

We studied the impact of a simulated telemedicine transport application on neonatal transport team stakeholders’ communication and situational awareness. When evaluating participants perception, comprehension, and projection of events in the transport context, the T-MAC application was associated with benefits for both MCPs and PCCTs, but there appeared to be a greater benefit of teletransport applications for the MCP group. Use of the T-MAC also reduced the amount of time both the MCP and PCCT spent on phone communication. To the author’s knowledge, this is the first examination of the impact of a monitoring and communication application in neonatal transport on situational awareness for both MCPs and PCCTs.

The role of the remote MCP in supporting the PCCT can be facilitated by access to real-time information from the transport environment.¹⁴ The perception, that is, the recognition of the patient’s status, is facilitated by access to clinical information and vital signs. This study showed that increased perception which contributes to the MCP and PCCT’s understanding of the significance of the change in the patient’s status, and what it will likely become, improving decision-making and patient safety⁵ was facilitated by the T-MAC application. Optimizing situational awareness through altered or integrated monitor displays and intelligent alarms has been explored in anesthesia and surgical settings.^15–18 During unanticipated events, remote access to vital sign trends ensures that the MCP and destination facility can receive timely updates, which may have implications for the receiving team’s preparedness to care for the incoming patient. With technology to support remote monitoring and communication, these updates can occur seamlessly while the PCCT remains appropriately focused on the patient.

Situational awareness scores suggested the T-MAC app to be somewhat useful for the PCCT. While situational awareness has been described as critical for professionals in all health care roles,¹⁴ prior studies have suggested that physicians and transport teams may have different attitudes and expectations towards telemedicine.¹⁹ The higher perception scores before the event suggest a benefit in alerting PCCT team members to the patient’s initial status. This may be facilitated by presenting the clinical information and vital signs in an integrated and accessible format. However, after the patient event, the situation awareness scores of the PCCT during the T-MAC scenario were similar to, or lower than, their situational awareness scores in the no T-MAC scenario. This suggests the T-MAC provides little to no benefit to the PCCT intratransport, as being at the patient’s physical bedside with access to real-time vitals and monitors adequately supports their understanding of the patient status.

Teletransport applications can facilitate communication and information sharing between transport stakeholders through asynchronous mechanisms. While phone calls, which are the current standard of care, may still be required, access to the T-MAC app decreased the duration of intratransport calls between the MCPs and PCCT. This may be due to MCPs requesting less information on the phone from the PCCT when information could be accessed within the T-MAC app. This decrease in call length may also have the benefit of allowing the PCCT to focus on discussing transport plans and patient care. Prior studies suggest that telemedicine improves communication among clinicians.^20,21 Increasing efficiency in information sharing is particularly relevant in pediatric settings when providing care to fragile newborns or children with medical complexity may require aggregating information from many sources^20,21

Limitations

This study had several limitations. It was conducted at 2 academic institutions with a dedicated PCCT consisting of a registered nurse and respiratory therapist. The findings may not translate to unit-based transport teams or teams with a different composition that includes neonatal nurse practitioners or physicians. The transport communication protocols used in this study may not perfectly align with those of other institutions. However, it is likely that most transport teams have some form of phone communication protocol in place. Participants were not given a prescribed text for phone conversations, which may have impacted the time spent on the phone for each group. However, the scenario information provided to both groups was the same. While all participants received an orientation to the T-MAC application before the scenario in which it was used, participants may not have used all available features of the simulated T-MAC application during the scenario, so the results may not fully reflect the potential of teletransport applications for improving situational awareness for PCCTs in intratransport settings. Future studies will iterate on the design for the T-MAC application, particularly for the PCCT, to better emphasize the features they reported as most valuable, develop a higher fidelity application for use in transport simulations, and expand the T-MAC application to support a broader range of pediatric interfacility transports. This study focused exclusively on neonatal patients and may not fully reflect the potential or limitations for pediatric interfacility transport, where there will be no neonatal incubator and a patient may or may not be able to communicate directly, among other differences. Future studies will investigate the impact of the T-MAC on pediatric transports. This study used only 2 patient scenarios, one per communication protocol. These scenarios were designed to be equivalent in difficulty, type of intervention needed, and expected communication. The results do not reflect the potential benefit and use of the T-MAC on more or less complex conditions.

CONCLUSIONS

This clinical simulation study compared the situational awareness of MCP and PCCT participants using a teletransport app and the current standard practice of communicating through phone calls. The teletransport application supported the MCP role by providing greater real-time access to the intratransport patient status. This led to greater situational awareness scores and shorter duration of calls with the PCCT. While the PCCT use of the T-MAC supported greater situational awareness at the patient’s bedside before departure, being physically present with access to real-time monitors made the monitoring features less meaningful during transport.