What Whiteboards in a Trauma Center Operating Suite Can Teach Us About Emergency Department Communication

Background 

Analysis of adverse events frequently points out failures in communication as one of their root causes in surgery,1 intensive care,2 general medicine,3 and emergency care.4 In emergency care, communication of physicians and nurses is often challenged by interruptions5, 6 and high levels of ambient noise.7 Although verbal interactions are the primary channel for communication,8 they are but one of a number of channels used for communication.9, 10, 11 To communicate and access information, care providers make use of a large number of information-rich artifacts around them, such as charts, computer terminals, and patient status boards. Tracking systems, traditionally handwritten whiteboards,12, 13 though now often electronic displays,14, 15, 16, 17 play a significant role of communication and coordination. A recent observational study showed that 24% of communication events occurred at the whiteboard in an adult emergency department (ED).18 Although no published reports were found on the prevalence or importance of whiteboards in hospitals, studies suggest that they are used widely.15, 19 Whiteboards’ large sizes enable instant, at-a-distance views, from different locations and by multiple people (so-called what you see is what I see). Such characteristics are important for many health care workers who are highly mobile and often rush to attend to competing tasks.

Importance 

Paper forms, printouts, and traditional whiteboards may seem mundane or even trivial, yet these information-rich artifacts frequently have a direct impact on communication and workflow.20, 21, 22

Understanding how information artifacts are used to support communication can inform us about information needs of clinicians and about their preferences of solutions in challenging settings such as the ED. For example, replacing traditional whiteboards with electronic tracking systems may weaken communication if we do not understand fully how traditional whiteboards support collaborative work,19, 23 especially in emergency medicine, in which physicians and nurses frequently rely on these artifacts to track and organize their work. With advances in networking and displaying technologies and increased deployment of electronic whiteboards,14, 16, 24 understanding information needs in collaborative work can drive optimal design and implementation of technology.25, 26

Objective of the Study 

To better understand the use of a common type of artifact in many care settings, we observed and analyzed staff’s interaction with and around a traditional whiteboard located in the hallway of a trauma center’s operating rooms. Some of the findings from the point of view of computer-supported collaborative work have been reported.27 In the current article, we focused on the implication to communication in emergency medicine settings. We analyzed the uses of the whiteboard as an information artifact in collaborative work based on observations and the key characteristics of information artifacts that contributed to their communicativeness.

The trauma operating room team members studied share many challenges and characteristics of their work environments with those working in an ED. They are multitasking, constantly on the move, and spatially distributed over multiple locations. There are several transitions among providers for each patient’s care. Incoming task loads are unpredictable and may easily exceed available resources. The length of time a room or a care provider may be busy with the care of a patient is highly variable. Furthermore, the atmosphere of a trauma center shares many cultural aspects with emergency medicine: an overriding intent to save lives and limbs regardless of time of day or status of patient, a sense of being the safety net for individual patients and for society, and a comfort with the unknown and unknowable. Many of the basic information challenges are also similar, including ensuring that blood tests, radiographs, or studies are completed at the correct time and tracking the progress of multiple admissions over time. The overall purposes of status whiteboards—to coordinate and track patients, tasks, and resources—are the same in the 2 environments. We believe that the analysis in trauma operating rooms contains important lessons for communications in rapid-paced, sometimes chaotic ED settings. To our knowledge, no equivalent study has been published from ED observation.

Distributed Cognition, a Theoretical Model of Communication in Collaborative Work 

We based our analysis on the theoretical model of distributed cognition. The distributed cognition model uncovers the integral role of artifacts in cognitive activities, especially how workers configure and manage spaces to simplify their cognitive tasks in making choices, detecting problems, and solving problems visually.28 In contrast to traditional models of cognition, distributed cognition studies people and their work environment as a single “cognitive system,” in which cognitive activities are carried out jointly by people with their tools. Cognitive activities are described as distributed across individuals and their environment. In the context of collaborative work, shared visual representation enhances communications while reducing the effort of explicit communication. Research according to the distributed cognition model examines in detail how shared visual spaces are tailored and tools managed to support communication.

Two pioneering examples using the distributed cognition model were studies on aircraft cockpits29 and naval ships’ chartrooms.30 In these 2 studies, cognitive activities (eg, memory and team coordination) were modeled by how workers exploited artifacts around them to accomplish cognitive tasks. For instance, navigation teams used maps, rulers, and pointers as external reference pointers for sharing information and for registering task status. Performance of cognitive tasks depends on how workers are supported by their environment (external representation) and by workers’ knowledge (internal representation).31

Field Observations in a Trauma Center 

After approval from the University of Maryland School of Medicine institutional review board, ethnographic observations were conducted in a 6-room surgical suite, which was dedicated to a regional Level I trauma center with 90 beds and 7,000 annual trauma admissions. Change was constant, unpredictable, and ongoing in the trauma operating room. Examples of change, many of which reflect similar situations in EDs, include cancelled surgeries, unexpected emergency surgeries for newly admitted patients, multicasualty situations in which demand exceeds resource supply, unavailable or malfunctioning equipment, lack of supplies, and unexpected shortage of staffing.

The distributed cognition model was used to guide observation and analysis on a traditional whiteboard (operating room board) used for coordinating operating room activities. Collected data were in the form of observational notes, interview summaries, and photographs. During 5 years, 10 observers with different backgrounds (nursing, anesthesiology, cognitive engineering, and informatics) participated in more than 200 hours at different times of the day and during weekdays and weekends. More than 300 photographs of information objects were taken. Photographs were processed to remove any patient identifying information. These photographs complemented the interview data to allow the development of a deeper understanding of mechanisms by which artifacts support collaborative work.

Data Analysis 

Accumulated data were discussed and analyzed at a series of research group meeting sessions by the multidisciplinary research team. Emerging categories of data were identified and adjusted to accommodate new data collected throughout the course of the study. Categorization and description of whiteboard tasks were discussed with clinicians working in this environment for clarification and explication. Finally, data were sorted to correspond to and provide exemplar descriptions of each category.

Description of the Whiteboard 

The whiteboard was located in a hallway, a strategic location that was restricted to operating room staff and was used for entering and exiting the operating room suite, such as for breaks. Staff from surgery, anesthesia, nursing, housekeeping, supply, patient transport, and administration frequently congregated and passed by the hallway. In addition to the whiteboard, which served as a large communal display, the staff configured the hallway with a number of information artifacts to achieve communication and rapid access to information, such as a variety of computer printouts of staff call schedules, pager numbers, case schedules, and a bulletin board for notices and announcements.

The magnetic whiteboard measured 365×122 cm (12 feet by 4 feet) and was partitioned into 4 columns (Figure 1). The first 2 columns were for holding cases for the 6 operating rooms (what cases were scheduled for which rooms and in what sequence). The third was for “parking” cases that had not been assigned a room, especially for unscheduled (“add-on”) cases (what cases were requested and in what priorities). The fourth was for nametags of nurses, technicians, and anesthesiologists. Throughout the board were various messages posted in paper, placed under magnets, or annotated by erasable markers directly on the board.

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Figure 1. The operating room whiteboard used by operating room staff. The ferrous board measured 12×4 feet. Each surgical case was written on a magnet strip, which was then assigned to a room (left 2 columns), or in the “parking” area (right column). Darker strips (blue) were for unscheduled cases on the waiting list. Staff was represented by magnetic nametags placed for each room. Patient call slips (for transportation orders) were placed under case strips. The fourth column (shown partially on the right) held nametags and had an area for representing staff for different shifts of the day. Note the slanted strip on the upper left corner (the case was finishing).

Eight Ways the Whiteboard Supported Collaborative Work 

We identified 8 ways in which whiteboards support collaborative work. Some of these may seem obvious, but they are examples of how much an artifact (here, the whiteboard) can become part of daily practice. The roles that whiteboards play may be subtle and may be missed in design of replacements. For example, large electronic display boards that replace whiteboards will not necessarily replicate the functions that the whiteboard has grown to accommodate. The means by which the whiteboard supports collaborative effort in the ED are readily seen through the window provided in the trauma operating room suite.

Team attention management 

Case strips were annotated by various operating room staff continually to direct staff’s attention (Figure 2). Notes about patients were frequent, such as “Spanish only,” “very large,” “ventilated,” “in testing until 9 am,” “isolation risk.” An interesting example was when information for surgeons not on record (eg, residents) was added on the strip, often by residents themselves, so that they could be contacted.

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Figure 2. Annotation. The strip was annotated (in red ink) to call attention to certain aspects of the case (“very large” and ventilator settings).

Task status tracking 

The operating room board was marked frequently to denote exceptions of case status (Figure 3). Abbreviations and symbols were used to indicate “no consent,” “patient here” (for outpatient surgery), “not cleared” (medically), and “need neurological clearance.” When same-day surgery patients’ arrival was confirmed, a dot was marked beside the case strip. When the call slips (Figure 1) for patient transportation were placed under the case strip, one could tell that the patient’s status and location was confirmed but the patient was not called for yet. When an add-on case strip was moved to an operating room area, the surgeon passing by could tell that his or her case was assigned and in what order the case was scheduled. The progression of a case was visualized for anyone passing by the board to see.

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Figure 3. Status tracking added to strips. Top: The 2 strips were marked “needs neurological clearance,” “no consent,” and “not cleared.” Middle: The strip was for a same-day surgery case, in which the patient was confirmed to have arrived and a dot (to the left of the strip) was marked. Bottom: the bottom strip was marked “patient not here yet at 7:20; no date; no signature.” (Note that writing was directly on the whiteboard.)

Task articulation 

Operating room staff used the board extensively and creatively to transmit signals of task transition among staff. Surgical staff were seen “tilting” case strips to indicate that cases were closing (signaling to others to prepare for transport and to get the next case ready). Figure 1 (upper left corner) shows one example. Operating room charge nurses moved transport call slips, which provided details of patient transport to the operating room, from under one side of case strips to another to indicate that the operating room was ready for the patient (Figure 4). That was a signal to the transport technician (and possibly anesthesia care providers) to bring the patient to the operating room. By taking the call slip with them, the transport technicians signaled that the patient was being transported to the operating room (and thus would arrive momentarily).

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Figure 4. Signaling. One case strip at 6:27 am (top) and 7:14 am (bottom) of a workday. The “call slip” (patient transport order) was moved from the right of the strip to the left to signal to the transport technicians that the specific operating room was ready for the specific patient.

Resource planning and tracking 

In the morning, nursing staff usually met in front of the board to look at what cases were scheduled for the day and to assign themselves to different operating rooms (by positioning nametags on the board). Skill requirements, training needs, and individual preferences were considered and negotiated together. The board supported group cognition so that staff could pick their own cases by understanding what needed to be done and assess their share of the workload.

Operating room nurses worked several types of shifts. Their breaks needed coordination. For example, an early-shift nurse would be given an early lunch break. To keep track and to communicate staffing status and decisions, magnets and notations were used, such as check marks and icons (Figure 5). In a single display, both resources and demands (staff and cases) were graphically represented. As the day progressed, changes in supply and demand were physically manipulated on the whiteboard, which served as a communication and collaboration tool that would store, process, and represent the current situation, as well as communicate to all team members.

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Figure 5. A “sunglasses” magnet was placed on a nametag (RAMON) to indicate that the nurse worked an early shift. The check mark on the left indicated that the nurse had a lunch break already. The nametag next to it on the right (RITA) was the nurse for the next shift.

Location and Installation for a Common Information Space 

Strategic locations for placing information artifacts are key to ensure ease and control of access. The operating room board in our study was located in a hallway, together with a telephone and a bulletin board. Operating room staff came to the location frequently to exchange information and to socialize. Careful consideration of other aspects of shared displays, such as viewing ranges and angles, are equally important.32 To satisfy requirements for control and ease of access, multiple boards reporting similar information may be needed.10, 14 Sharing information not only allows knowledge of the information but also confirms the awareness that other people have access to the same information.10

The sheer size of the operating room board facilitated multiuser input and problem solving. As opposed to other installation options (eg, near the ceiling), the operating room board was hung with its center at roughly eye level to encourage staff to work side by side, using pointing and eye gazes to support joint planning, situation assessment, briefing, and negotiation. Areas near a whiteboard were found to be a preferred location for verbal exchanges.18

Although our studies were focused primarily on the operating room board, care providers we observed maintained and managed information around the hallway where the operating room board was located and throughout the surgical suite.21, 33 For example, call schedules were printed and posted near the telephone, where such information was frequently consulted.33 Strategies of posting information at locations where it was mostly likely needed were observed in other settings.10

Accessibility and central location are 2 characteristics of whiteboards common to EDs without electronic tracking systems. Distributed electronic systems, although allowing the same information to be replicated easily, do away with the socialization and team building that a central board encourages. Additionally, hanging monitors near the ceiling impedes easy interaction, some aspects of visibility, and the possibility of attaching other documents in the vicinity of the shared visual space.

Interactivity and Usability 

Annotations, updates, and grouping of information items on the operating room board further amplified its utility for conveying joint activities. In addition to passively observing the operating room board, staff continuously maintained and tailored information objects on the operating room board. When decisions were considered or made, changes could be made directly on the board, which allowed examination of potential problems.27 As such, direct manipulation of information and visually reviewing of proposed changes were supported by the operating room board. Similar strategies have been observed in an ICU, in which physical objects such as Lego pieces with magnets were used to annotate a large display of schedules.34 Staff in that study “copied” information from online sources to traditional whiteboards and then used the copied information as a basis for annotation.

Easy-to-use interfaces, such as traditional whiteboards, are key to having frequently updated common information. Some barriers to usability that may seem trivial at first glance, such as having to walk to the input terminals, go through multiple screens and menus, and signing on, can discourage data maintenance.19 There is usually sufficient real estate on a white board to allow all staff members some space. In contrast, it is often difficult to modify limited fields on a computerized tracking system used in ED.

Expressiveness 

The operating room staff exploited the operating room board to convey information rich in all the subtleties and nuances of complex organizations with inherent conflicts and frequent changes. Changes were often made highly noticeable through such techniques as marking lines through a case to indicate cancellation, writing in different colored pens for additions, or annotating by different people with distinct handwriting. The operating room board placed few restraints on data representation. The operating room staff exploited this characteristics to express ambiguous status (eg, the patient may be “cleared” for surgery), noncommittal expectations (eg, assigning a case tentatively while not committing to the decision), and contextual information (eg, blood test results of the patient).

Clinicians are familiar with paper, whiteboards, and other traditional information artifacts. These tend to be simple to use and relatively intuitive. Users are adept at inventing ways to represent and communicate nuanced complexities facing clinicians.33 These complexities evolve over time and create changing demands for users to represent information visually. For example, operating room charge nurses used blank case strips to form an “X” in an operating room to indicate that the room was closed because of contamination. As a consequence, cases had to be rearranged completely. Operating room staff who came to the board noticed the salient cue immediately.

Some of the information represented on the operating room board was tentative and suggestive. Latest blood test results were placed under case strips several times to update on the possibilities of case canceling. In one example, the case strip was placed upside down, with annotation that the patient was coded overnight, although the case was not yet officially canceled. In several cases, the surgeons were not sure exactly what procedures would be performed. The operating room charge nurses wrote on the board to indicate this uncertainty (“possible flap”).

Like a trauma operating room, the ED is a constantly changing environment subject to external factors. Modification costs of a whiteboard are minimal. There are no special keystrokes required, for example, to augment the comment field in a comparable computerized system, in which staff may often feel uncertain as to who “owns” the comment field. Staff in EDs are known to use “private signals” on whiteboards for their own benefit; for example, a dot or square is used to indicate a patient who awaits reevaluation.

Visibility of Transition Points to Support Work Handoffs 

The operating room board was exploited by the staff to place signals or semaphores to trigger subsequent activities for work handoffs. Coordination in emergency care is challenging in part because of the uncertainties and rapid pace of events. Care providers are required to “articulate” their activities through mutual adjustment for when, how, and what activities one should perform.35 The call-slip example in Figure 4 demonstrates how semaphores were placed on the operating room board. The ability to visually signal timing and even exact next steps has been suggested as critical to remove ambiguity and to improve consistency and reliability of performance.36

In the ED, a central whiteboard provides an obvious gathering space for sign-out rounds, which is best exemplified in an academic setting in which the entire department may gather around the board at various intervals. The obvious gathering of physicians encourages notice and involvement by other staff, whereas an isolated sign-out around a computer-based tracking system replicates the hospital’s underlying silo structure: physicians gather with physicians, nurses with nurses.