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By Bryan Harmer, PhD, CCP, FAEMS

Prehospital emergency care is characterized by high stress, rapid decision-making and a diverse array of patient encounters. These characteristics, combined with various other factors found in the prehospital setting, can contribute to suboptimal care.

Several studies have identified that various aspects of EMS care are associated with high rates of medical errors and other events that can negatively impact patient care [1–5]. Traditional methods of addressing these issues in EMS have largely revolved around enhancing training programs designed to improve knowledge retention and skill execution — essentially attempting to train their way out of the problems. While education and practice are undeniably critical, they can only go so far. Human beings have limitations to their cognitive abilities and are thus fallible. These factors call for system support to aid EMS clinicians in making effective and efficient decisions during patient care.

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One form of system support, often used in high-reliability organizations, is the cognitive aid. Cognitive aids are practical tools often designed to assist the user in making quick, accurate decisions during high-pressure situations. In emergency medicine, they often include checklists, algorithms, flowcharts or simple reference aids [6]. Cognitive aids can help clinicians rapidly recall vital information, cognitively offload mental tasks and ultimately adhere to best practices. They can also enhance team communication and coordination during complex medical scenarios, contributing to improved patient outcomes in emergency settings.

Cognitive aids have been the subject of research for many years in other areas of medicine and often show significant benefit to patient care [7–9]. However, research on the use of cognitive aids in EMS is somewhat limited. Although the aids that have been investigated in EMS typically show value toward their intended purpose, they should be carefully considered and preferably tested prior to their implementation in patient care [10–12]. A poorly designed aid, or one with incorrect information, could have a profoundly negative impact on patient care.

Cognitive aid considerations

There are many cognitive aids available through publishers, mobile applications and other resources that EMS clinicians may wish to use during patient care. However, it is likely that most of these aids have never been tested to examine their efficacy or effectiveness. The following are some basic steps to consider when selecting or designing an aid for use in EMS.

1. Identify the purpose: Clearly define the specific problem you aim to address with a cognitive aid. The most appropriate solution may not be a cognitive aid, but rather a more comprehensive system change (e.g., better equipment or work schedules). If a cognitive aid is the best solution, consider whether and how the proposed aid could address the issue.
2. Build a team: If you are designing an aid, it is essential to assemble a multidisciplinary team. This could include engineers, physicians and even user interface (UI) and user experience (UX) designers, but should always include the end users (paramedics and EMTs). You may want to use this team approach even if you are choosing an aid that was previously developed. The team may provide insight into appropriate use of the aid for EMS.
3. Analyze the task or process: Identify if the aid is being used for a specific task (e.g., endotracheal intubation) or if it would guide a larger process (e.g., cardiac arrest management). You may want to consider conducting a task analysis or workflow analysis to better understand the task or process you are integrating the aid into.
4. Design the user interface: If you are designing a cognitive aid, consider principles of usability, including clear navigation (if digital), readability and visual appeal to enhance user engagement and accessibility. A UI/UX designer can help guide this process and offer best practices for design features.
5. Prototype and test: If you are designing an aid, build a prototype and conduct usability testing with intended users. Collect feedback to identify areas for improvement, focusing on both content clarity and user experience. Additionally, examine its efficacy in addressing the problem it was designed for before implementing it in the field. Both usability and efficacy testing can be conducted by carrying out simulations with EMS clinicians.
6. Implementation planning: Develop a strategy for integrating the cognitive aid into clinical practice. This includes determining how to roll it out, training users and ensuring they understand its application.
7. Evaluate its effectiveness: After implementation, monitor the cognitive aid’s impact on clinician performance and patient outcomes. Collect data and user feedback to assess its effectiveness. Identify any ongoing issues, update and maintain the aid to ensure it addresses its intended purpose.

These steps are fundamental to ensuring that the cognitive aid effectively addresses its intended purpose in a safe manner. There are several additional steps to consider when developing or selecting a cognitive aid for use in EMS, depending on the complexity of the aid or the process for which it is developed. Although this process may seem daunting, the biggest challenge may be getting EMS clinicians to use these aids during patient care.

Promoting cognitive aid use

Harmer et al. conducted a cross-sectional survey with six participating states examining how frequently 15 cognitive aids were being used in EMS for their intended purpose [13] . The study found that overall cognitive aid use was limited. In a second article, Harmer et al. published a planned subsequent analysis examining factors associated with increased use of these aids [14]. The study identified three key factors that may help increase the use of cognitive aids in the prehospital setting:

1. First, it was found that respondents who reported using a cognitive aid during their initial education programs, such as paramedic or EMT programs, were significantly more likely to use the aid during patient care.
2. Second, the study revealed a notable increase in reported use of a cognitive aid when respondents indicated they were mandated by a policy or protocol to use it.
3. Finally, the study found that when respondents perceived a cognitive aid as useful, they were significantly more likely to use it during patient care.

These factors emphasize the importance of implementing training and policy procedures, as well as promoting the usefulness of aids when introducing them into EMS practice. By addressing these elements, EMS organizations can foster a culture that values the use of cognitive aids, ultimately enhancing the quality of patient care. Therefore, focusing on education, policy reinforcement and perceived usefulness is crucial for improving the integration of cognitive aids in EMS.

Harness the full potential of cognitive aids

Cognitive aids can be highly beneficial tools in EMS, serving to enhance patient care and clinical performance. However, they must be meticulously examined and tested prior to implementation, as poorly designed aids can lead to adverse outcomes for patients. It is essential to ensure that these tools are not only reliable but also tailored to meet the specific needs of EMS environments. By prioritizing a rigorous development and evaluation process, EMS organizations can harness the full potential of cognitive aids to improve patient outcomes.

ABOUT THE AUTHOR
Dr. Harmer has over 20 years of experience in EMS across southern Michigan. He is currently a postdoctoral research specialist at the University of Michigan School of Medicine and an adjunct clinical assistant professor in the Department of Emergency Medicine at Western Michigan University’s MD School of Medicine. He holds a doctorate in Interdisciplinary Health Sciences from Western Michigan University. His research focus is on human factors in EMS patient safety.

REFERENCES

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