 “GSW to the left leg. BP 132 over 82. Pulse
110,” says the paramedic as he rushes a patient with a gunshot wound
through the doors of the trauma center. What may seem like a chaotic
scene to the casual observer is actually the seamless exchange of vital
information and mixing and matching of trauma team members – as
expertise dictates – in a display of coordination unlike any other
workplace on earth.
“When dealing with critically injured patients, you have only a
narrow window of to stabilize the patient before the body goes into
shock and shuts down,” says Samer Faraj, associate professor of
information systems at Smith. “Time is of the essence and coordination
among the trauma team is very important.”
Faraj defines expertise coordination as the way in which information
and skill interdependencies are managed. To a spectator of a trauma team
in action, it might seem like everyone knows what to do and when to do
it. In reality, the process is highly uncertain. The extent of a
patient’s injury and medical history is often unknown. Trauma centers –
like other high reliability organizations (air traffic control centers,
nuclear power plants) – rely on very specific protocols to ensure that
each patient receives the best treatment.
With two grants from the National Science Foundation totaling
$700,000, Faraj has been studying coordination in trauma centers since
1999. “I went into the project aiming to study coordination failures,”
says Faraj. “I thought there would be errors, but it turns out I was
asking the wrong questions. A nurse once told me, ‘we don’t have
coordination failures: we don’t allow it.’ That is when I decided to
focus on the coordination practices that reduce failure.”
R. Adams Cowley Shock Trauma Center at the University of Maryland in
Baltimore, Md., is the oldest of three stand-alone trauma centers in the
U.S., and often called the best trauma center in the world. Faraj and
his team spent 18 months there studying coordination practices. Working
with Seokhwa Yun, PhD 2001, they conducted interviews, observed patient
admissions and operations, and shadowed key personnel.
“The paradox of the trauma center is that there is tremendous freedom
and constraint at the same time. It is a totally different setting than
a hospital,” says Faraj. “Besides the time pressure, the decisions are
all negotiated around what is best for each patient. For example, if the
anesthesiologist doesn’t feel like the patient can be anesthetized,
he/she can override the desire of the surgeon to operate. If the nurse
feels like a patient is in danger, he/she can refuse to obey orders.
That is at the heart of a high reliability culture,” explains Faraj.
There is a fine line to be walked between empowering the front line
caregivers and retaining control over the care being provided. “You must
empower the front line, but if you do, lives could be lost because some
hot shot surgeon wants to push the envelope,” says Faraj. “On the other
hand, rules are limiting as you cannot pre-specify every action. That is
where expertise coordination practices – or ‘dialogic coordination’ –
come into play. In an effective high-liability organization,
practitioners develop specific practices and workarounds that balance
between the protocols in place and what expert judgment requires one to
do in order to save the patient.”
After understanding coordination practices, Faraj focused his
research on the use of information technology in the trauma center.
Faraj and Sharyn Gardner, PhD ’03, surveyed 308 trauma centers
throughout the U.S. to understand what communication technologies were
most valuable in trauma settings. They found that trauma centers
preferred reliable and simple communication technologies, such as the
overhead page, because of the potential catastrophic impact of a
technology failure.
Now working with Smith’s new Center for Health Information and
Decision Systems (CHIDS), Faraj is studying the implementation of a
“Vocera badge,” a voice-controlled wearable device that connects
hospital staff and patients on a wireless network at St. Agnes
Healthcare in Baltimore, Md. “Basically, this technology allows
person-to-person direct communication and reduces the need for overhead
pages and beepers. It is surprising how much quieter the hospital floor
is without all the paging back and forth,” says Faraj.
Earlier in his career Faraj centered his research on the impact of
information systems on organizations. He says that his current attention
on the medical field has really hit a chord. “It is a heartening feeling
to know that your research may help improve care and ultimately save
lives,” he says.
By Alissa Arford-Leyl |
