Interactive cognitive artifacts for enhancing situation awareness of incident commanders in mass casualty incidents
© Mentler and Herczeg. 2015
Received: 25 November 2014
Accepted: 21 July 2015
Published: 19 November 2015
In mass casualty incidents, several members of Emergency Medical Services have to take actions in the field in order to cope with many injured or sick people. Incident commanders are responsible for managing operations, guiding rescue forces and applying resources appropriately under extraordinary circumstances. Data required for situation assessment, projection of developments and decision making are gathered by many different emergency physicians and paramedics. They are shared by numerous face-to-face talks, radio and phone calls as well as with the aid of paper-based forms and notepaper. While these tools and means of communication support flexible modes of operation, they often lead to deficient awareness of the situation. Due to temporal delays, poor handwriting and incomplete data, information sharing in the field is hampered, delayed and faulty. Compared to established paper-based artifacts, interactive cognitive artifacts might improve the situations by exchanging and visualizing data in real-time. However, because of users’ workload and working conditions, designing mobile computer-based tools and systems for this context of use is not only a technical but also a usability challenge. Based on the results of a two-year user-centered system design project in cooperation with German Emergency Medical Services, we discuss currently used and interactive cognitive artifacts for incident commanders. Challenges and approaches for successful user interface and interaction design are described and future work is outlined.
In general terms, Emergency Medical Services (EMS) are “[…] the ambulance services component that responds to the scene of a medical or surgical emergency, stabilizes the victim of a sudden illness or injury by providing emergency medical treatment at the scene and transports the patient to a medical facility for definitive treatment” . With respect to this definition, regular medical transport or emergency missions with one or few patients need to be distinguished from mass casualty incidents (MCIs) with larger number of patients. While the former are accomplished on a daily basis, the latter are rare events for EMS employees. Due to an at least temporary mismatch between patients and medical staff they require adapted tactics and workflows. Standards of individual treatment would require too much time and too many resources. They could only be preserved to the disadvantage of many respectively in favor of few.
a steady flow of information between incident command and operational units,
usable tools and aids for information management.
Theses aspects represent complex challenges in preparation of and during a MCI. Domain experts and tool providers need to cooperate in order to develop practical solutions. The basic research questions of this contribution are, which cognitive artifacts are currently used by incident commanders and how interactive cognitive artifacts have to be designed in order to ease and optimize incident commanders’ work.
Background and related work
observations of two MCI exercises in different federal states;
five workshops with EMS employees of different rescue services at which concepts and prototypes regarding the interactive system were presented and evaluated formatively;
numerous interviews with incident commanders, emergency physicians and paramedics;
two days of discussions with professional visitors at our booth at a large emergency trade fair.
The project resulted in an advanced prototype of an information system for managing MCIs, which has undergone formative and summative evaluations [3–5]. Related work has been conducted with respect to information exchange with maps and tactical signs in emergencies  and combinations of computer-based and paper-based area maps .
Mass casualty incidents
Train and airplane accidents or terrorist attacks often result in publicly recognized MCIs. Nevertheless, even minor events can generate “more patients at one time than locally available resources can manage using routine procedures” . Contributing factors can be time of occurrence (e.g. at night), location of accident (e.g. freeway, poorly accessible areas), weather conditions (e.g. heavy rain, snow, storm), and utilization of responsible EMS (e.g. while being in charge of other events at the same time).
Managing MCIs efficiently will only be possible, if operations are co-ordinated and EMS members led by superiors. Courses of action need be coordinated and a spatial order has to be established (tactics). Triage, i.e. efficiently determining severities of injuries and prioritizing treatments, is regarded to be the most important task following basic life support actions . It implies an order in which casualties are transferred from triage to transport. The process should be supervised by the chief emergency physician and supported by the ambulance incident officer. Furthermore, they are responsible for organizing and running specifics areas of operation for triage, treatment and transport. A specific flow of information between the incident commanders and these operation areas is crucial for performing actions in classified order. They have to be documented as complete and comprehensible as possible. Physicians in charge at hospitals receiving victims of MCIs have to rely on these records. Furthermore, EMS employees who are still waiting for being involved should be informed about the following mission.
Treatment, i.e. medical care of ill or injured people, and taking care, i.e. crisis intervention and emergency pastoral care, need to be adapted to the circumstances. Standards and procedures of individual care would be too time-consuming or resource-intensive. Finally, casualties need to be taken to clinical environments for further treatments (transport).
Situation awareness in MCIs
Perceiving environmental elements is affected by their spatial distribution and permanent movement (e.g. arriving and departing ambulances, wandering patients and EMS employees).
Comprehending their meaning is complicated by disturbances and various stressors (e.g. noise, number of casualties, conflicts of competence, mission lasting several hours, leaving injured people behind).
Projecting the future is limited by suddenly changing settings (e.g. physical condition of casualties) and occupied cognitive resources (e.g. by making decisions or coordinating resources).
Tools and aids for record keeping and information management should support incident commanders’ work and decrease their workload while accomplishing several unusual tasks in parallel and under time pressure.
Cognitive artifacts in MCIs
Cognitive artifacts can be defined as “artificial devices that maintain, display, or operate upon information in order to and suitable serve a representational function and that affect human cognitive performance” . On different levels of abstraction they represent entities and relationships which are of peculiar interest in a specific domain . With regard to MCIs, these are patients and their medical conditions as well as available medical resources (e.g. vehicles, physicians, utilization of hospitals). Some of them are locally available; others have to be requested from a distance.
Cognitive artifacts are meant to support and ease human problem solving as well as accelerate and improve task completion. However, from a personal view, introducing or modifying cognitive artifacts changes the way how people can accomplish tasks and how cooperation will be conducted . Incident commanders have been skilled in different topics (e.g. emergency medicine, command and control), but they are different from operators of other complex socio-technical systems (e.g. aviation) in several respects. First of all, they do not perform supervisory control on a daily basis. Crews for regular missions consist of 2–3 persons and work together as well-matched teams side by side. Secondly, although applying sophisticated medical technologies regularly, they are not used to interactive and multimodal human-machine interfaces in everyday professional life.
Cognitive artifacts represent “a meeting point […] between an ‘inner’ environment, the substance and organization of the artifact itself, and an ‘outer’ environment, the surroundings in which it operates” . In terms of EMS employees’ working conditions, the latter can hardly be planned ahead because MCIs can occur anywhere and anytime. In spite of that, they are rare events for a specific incident commander (cf.  for an exemplary analysis of a German district). Therefore, cognitive artifacts in this safety-and time-critical domain have to be suitable for the task, self-descriptive and conform to user expectations. Learning and adaption phases have to be avoided respectively minimized. Otherwise, such artifacts might be a danger to life and health or would not be used at all.
Cognitive artifacts for enhancing SA in MCIs
Currently, incident commanders mainly rely on paper-based cognitive artifacts [20, 21]. Forms and tables, maps and charts, and private notes can be distinguished and are discussed below. Because basic aspects like triage categories or crucial topics for incident commanders (e.g. number of patients still to treat), the selected examples of German EMS are comparable to the ones used in other countries [20–22]–although there is not even a nation-wide standard.
Forms and tables
summarizing time and result of each patient’s triage at the triage area;
documenting actions at the treatment area(s);
registering transport decisions at the staging area (e.g. vehicle, patient, destination, departure time);
recording hospital assignments in order to ensure balanced distribution;
organizing the assembly area (e.g. arrival and departure);
enabling quality management by consolidating data from different sources.
In addition to such mainly textual and tabular representations, graphical notations are established as well.
Charts and maps
Apart from using templates and published materials, many incident commanders record certain data individually.
Interactive cognitive artifacts
Questions of usability in this domain are rarely related to cognitive ergonomics, task analysis, human-computer interaction, or design (e.g. [22, 23]). Following some more general remarks to usable computer-based solutions in MCI management, challenges and approaches to cognitive ergonomic design of interactive tables, maps and note-taking are considered.
General remarks on usability
Developing interactive cognitive artifacts for the context of pre-hospital medical care is a challenge for various reasons. Interface and interaction should be designed iteratively and by user participation. However, short-term scheduling is complicated by work schedules and staff requirements.
Field studies and test runs can hardly be projected. Workshops, interviews and expert reviews often take place in conference facilities or office rooms. Such favorable conditions differ completely from the real context of use. Thus, natural environments, interruptions and other performance disturbing factors that characterize MCIs have to be considered specifically and carefully. What seems like an appropriate approach in a relaxed training situation might be a hardly manageable case of information overload in the field. Furthermore, computer-based tools and systems are an additional medium of communication and channel of information. They have to be aligned with established workflows and organizational structures which depend on thorough exchange of radio messages.
Because of possible difficulties arising from wearing gloves, touching accidentally or working with dirty hands, pen-based interaction should be supported by the system. Losing the pen might be an additional risk but it can be minimized by fastening it with a tear-resistant but flexible ribbon. Other input methods which are supported by state-of-the-art and off-the-shelf tablet PCs, e.g. speech or gestures, have to be judged critically. One the one hand, speech input usually demands high working memory resources of users and recognition rates could drastically decrease in noisy environments like MCI settings. On the other hand, gestures have to be remembered and performed correctly. This might be challenging with respect to weather or physical conditions.
Among other aspects, consistency can be ensured or improved by using well-known and appropriate layouts, data input widgets, visualizations, feedback mechanisms, error messages, symbols and colors. Although striving for it, certain screen layouts and interaction elements, which are important to MCI management, will not be used by incident commanders in their daily duty as regular emergency physicians or paramedics. One example is the distribution of triage categories shown in Fig. 6. Especially while dealing with well-known design issues for these parts, well-established design principles (e.g. ) should be considered. These best practices need to be applied to the specific context of MCIs . As they represent essential entities and relationships, currently used cognitive artifacts might be an appropriate starting point for this process.
In safety-and time-critical domains with highly skilled personnel, it seems advisable to build upon practical experiences. Furthermore, questions of automation, adaption, and individualization arise with respect to division of tasks between human and machine. User interfaces and interaction methods have to be designed with respect to hardware capabilities (e.g. screen size, resolution, input and output modalities) and context.
Challenges and approaches to ergonomic design
As mentioned before, incident commanders currently take private notes and work with various paper-based documents in order to enhance their SA. Some of them are stationary and others have to be delivered manually. They can be arranged, sorted, or marked by the user to a limited extent. Computer-based tools allow data access and exchange near real-time and from remote but offer only limited screen space. Feedback about incoming data must be given explicitly.
Forms and tables
efficient navigation between different sections;
comprehensive visualization of larger datasets;
fast browsing of numerous datasets.
Tabs, i.e. multiple screen masks within a single container and a navigational widget, can be used to group single tables logically and ease access. Another approach is to mark an item in one table and see links to related items in other forms. This requires efficient design solutions for backward and forward navigation, e.g. breadcrumbs.
Larger datasets might not be presentable in a single table row. Possible approaches would be folding out entries on demand or displaying detailed data of a marked entry in an overlay panel. Search options have to be available and should support phonetic search. By doing this, search results would be returned that sound similar to the given term. This might be important because incident commanders might not know correct spelling of some search terms, e.g. last names, or make typing errors while having serious time pressure. Moreover, in favor of searching by entering data freely, filter mechanisms should be implemented, if the range of values is limited. They would only offer proper values. Activated filters must be clearly visible, e.g. by changed background colors or other visual hints. Otherwise, the subset of displayed datasets could be perceived as the total set. Temporarily marking favorites, e.g. in terms of patients to remember, can be a feature to relieve incident commanders’ working memory and allow them to continue tasks later on more easily.
With respect to browsing larger datasets, paging and continuous scrolling are basic options. While the latter one is the most prevalent at mobile devices in general, we observed some difficulties with pen-enabled devices. Some users slipped of the surface while trying to move the pen up or down. Such difficulties could increase stress levels. Therefore, we recommend implementing a more fail-safe paging solution–at least in addition to the other one. Regardless of the approach, all interaction elements should offer a sufficient target area in order to deal with pen interaction challenges like occlusion.
Charts and maps
Data exchange with geographic information systems in emergency control rooms or command vehicles might be necessary. Moreover, some incident commanders and EMS managers expressed reservations about modifying situation maps by multiple actors. They were strongly in favor of a read-only mode for co-workers in the field.
Personal note-taking should always be possible and could be realized easily on a pen-enabled tablet PC. A digital notepad within reach of every screen mask can be a first step. It should support both handwriting recognition and freehand drawing. Advanced solutions could offer more shortcuts, e.g. for creating tables or marking entries in different colors, or support annotations of pre-defined user interface components, e.g. a digital triage tag with notes about the patient.
Due to several cognitive and emotional factors, MCIs are an extraordinary challenge, even for experienced emergency physicians and paramedics. SA is of the utmost importance for incident commanders. They are responsible for best possible treatment of patients and for an acceptable workload of EMS employees. Interactive cognitive artifacts could support their demanding work and improve on established equipment. In order to achieve this, workflows and organizational structures have to be adjusted, e.g. with respect to shared situations maps or less radio messages. In any case, design and usability of these artifacts will remain an interdisciplinary challenge. Participatory design has to be conducted leading to detailed user interface and interaction design solutions like single tables or bar charts. Users might only have little time to perceive and comprehend visualizations or be disrupted meanwhile. Compatible mental, conceptual and technical models are required to minimize mental workload, ease decision-making and ensure performance in the field.
Chief Emergency Physician and Ambulance Incident Officer have to form and lead a team in order to successfully manage a MCI situation. Shared resources and requirements have to be coordinated and met with respect to their specific areas of responsibility. Therefore, future work on interactive cognitive artifacts for managing MCIs should not just consider individual SA, but Team and Shared SA as well in order to further enhance the usability of interactive cognitive artifacts and cooperation support for EMS employees [26, 27].
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