Human and Automatic Machine Interaction in the Emergency Department in Situational Awareness Maintenance

Ideally, automation alleviates some burden on the human operator's cognitive load by making decisions based on what was programmed. At the same time, situation awareness is crucial in any decision-making scenario involving human operators. Since automation and artificial intelligence technology has not yet matured, many industries that utilize a collaboration between humans and machines require human overseeing. Therefore, the main idea is to get humans maintained in the decision-making process and using automation as assistance that facilitates information flow instead of the primary decision-maker. Once the automated machines are implemented to situational awareness amongst the emergency department (ED) team and augment the physicians' decision-making process, they will also help address the human shortcoming of limited working memory and attention.

Individual Situational Awareness and Automations

Unlike most medical fields, the ED consists of a high-intensity workload. Each physician needs to care for multiple patients within a certain amount of time and a constant turnover of patients, resulting in a rapid change in information. Therefore, maintaining situational awareness becomes essential to ensure a manageable working memory load and performance when working in such an environment. 

One importance of situational awareness is described by Levin et al. (2012). As Levin et al. (2012) state, the amount of information present in the work environment of ED physicians is so vast that physicians often need to separate patient-related information from other stimuli such as background noises. Background noises can include physical noises in the environment such as alarms or conversation or a surplus of information either from discharged patients or other irrelevant information. A failure in maintaining situational awareness about patient conditions risks sound desensitization when an alarm rings or not perceiving visual stimuli, resulting in mistakenly judging the stimuli as not an indication of their patients' condition. Therefore, an automated system can automatically alert physicians of a critical lab result and directly notify them instead of physicians keeping track or waiting for a critical lab result to return. This will greatly eliminate the number of tasks kept in the working memory and spare the extra attention to focus on present tasks and maintain situational awareness. Although the machine is not programmed to make automated decisions or actions, an automated system can help physicians maintain situational awareness. 

Team Situational Awareness and Automations 

Other than the already busy schedule and constant patient turnovers for the physicians themselves, coworkers within a care team present as another cause of a decline in a physician's situational awareness. Due to the ED's nature, information transfer is a common practice. There are two ways in which situational awareness decreases amongst team members. One is while physicians are on duty. Because a physician is responsible for multiple patients at a time and a particular patient will also have other members from the ED, such as a nurse or a specialist, taking care of a patient, physicians often need to answer other coworkers' questions while attempting to read a chart and make a decision. Weigl et al. (2020) discovered that any form of disruption, such as technical difficulties or phone calls, can affect a physician's workflow and affect the level of situational awareness.

Second way of losing situational awareness amongst team members occurs at hand-offs (Levins et al., 2012). This can occur in two ways. One is when off-duty physicians omit pieces of information when handling patients to newly on-duty physicians, causing the new physician to lack details on the treatments already done and the patient's current status. Second, newly on-duty physicians omit a piece of information even though the off-duty physician completely and correctly transferred the information. As Lowe et al. (2016) state, the collaboration of individual team members and their knowledge can enhance situational awareness amongst the whole team. Therefore, an automated system can compose physicians' orders with accompanying lab reports and present them to a team member to better relay information across team members. The automated system can enhance smoother information flow, thereby enhancing situational awareness on the team level and decrease physicians' working memory load, thereby increasing physicians' performance.

Can Automation Enhance Physician Situational Awareness?

With the present technology, automated systems are already widely implemented in industries such as aviation, as seen in auto-piloting, where machines can make decisions and human operators serve to oversee and take over whenever needed. However, similar technologies have not yet been widely implemented in the ED for reasons, one of which is mentioned in Bond et al.'s (2018) research. Bond et al. (2018) discovered statistically significant automation bias when physicians are presented with incorrectly diagnosed EKG. The presence of automatic diagnosis also affected confidence in their diagnosis. Issues arise when an automatic diagnosis is incorrect, which occurs 64% of the time (Bond et al., 2018). Automatic diagnostics have not yet advanced enough to work solely in the medical field to assist in major decisions. However, it can provide assistance to increase situational awareness on an individual and team level. Therefore, until further technological advancements, automated machines should help alleviate physicians' mental workload and facilitate information flow for both the physicians and coworkers to enhance individual and group situational awareness.

References

Bond, R. R., Novotny, T., Andrsova, I., Koc, L., Sisakova, M., Finlay, D., Guldenring, D., McLaughlin, J., Peace, A., McGilligan, V., Leslie, S. J., Wang, H., & Malik, M. (2018). Automation bias in medicine: The influence of automated diagnoses on interpreter accuracy and uncertainty when reading electrocardiograms. Journal of Electrocardiology, 51(6), S6–S11. https://doi.org/10.1016/j.jelectrocard.2018.08.007

Levin, S., Sauer, L., Kelen, G., Kirsch, T., Pham, J., Desai, S., & France, D. (2012). Situation awareness in emergency medicine. IIE Transactions on Healthcare Systems Engineering, 2(2), 172–180. https://doi.org/10.1080/19488300.2012.684739

Lowe, D. J., Ireland, A. J., Ross, A., & Ker, J. (2016). Exploring situational awareness in emergency medicine: developing a shared mental model to enhance training and assessment. Postgraduate Medical Journal, 92(1093), 653–658. https://doi.org/10.1136/postgradmedj-2015-133772

Weigl, M., Catchpole, K., Wehler, M., & Schneider, A. (2020). Workflow disruptions and provider situation awareness in acute care: An observational study with emergency department physicians and nurses. Applied Ergonomics, 88, 103155. https://doi.org/10.1016/j.apergo.2020.103155