Improving Antibiotic Resistant Infection Transmission Situational Awareness in Enclosed Facilities

169 Pages·2017·5.46 MB·English

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Theses & Dissertations Graduate Studies
Summer 8-14-2015
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Valeriya V. Kettelhut
University of Nebraska Medical Center
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Kettelhut, Valeriya V., "Improving Antibiotic Resistant Infection Transmission Situational Awareness in
Enclosed Facilities with a Novel Graphical User Interface for Tactical Biosurveillance" (2015). Theses &
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IMPROVING ANTIBIOTIC RESISTANT INFECTION
TRANSMISSION SITUATIONAL AWARENESS IN ENCLOSED
FACILITIES WITH A NOVEL GRAPHICAL USER INTERFACE
FOR TACTICAL BIOSURVEILLANCE
by
Valeriya V. Kettelhut

A DISSERTATION

Presented to the Faculty of
The Graduate College in the University of Nebraska
In Partial Fulfillment of the Requirements
For the Degree of Doctor of Philosophy

The Department of Surgery
Biomedical Informatics Graduate Program

Under the Supervision of Professor James McClay

University of Nebraska Medical Center
Omaha, Nebraska

June, 2015

Supervisory Committee:
James McClay, M.D. David Mercer, M.D.
Jane Meza, Ph.D. Ann Fruhling, Ph.D.
Trevor Vanschooneveld, M.D.
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ACKNOWLEDGEMENTS

I dedicate this work to my Dear Parents for their love, support, and encouragement to
pursue my dreams.
I wish to express my deep gratitude to my alma mater, Omsk State Medical University, and the
people who motivated me to study medical art and contribute to public health welfare through my entire
life.
I feel fortunate to have been a student in University of Nebraska Medical Center.
I am truly grateful to my advisor Dr. James McClay who taught me to work consistently and
systematically toward my goal. His support and push through the most challenging parts of this work led
me to finalize my research and exceed my own expectations. I also would like to thank Dr. McClay for
providing me with the opportunity to network with many prominent professionals in biomedical
informatics and learn about vast opportunities in biomedical informatics field.
I would like to acknowledge the members of my Supervisory Committee. I thank Dr. Jane Meza
for her guidance on statistical techniques and research methods she provided me throughout study. I thank
Dr. Trevor Van Schooneveld for sharing his knowledge and expertise in infectious diseases and
epidemiology and his contribution to the research studies that resulted in publications. I thank Dr. David F.
Mercer for his enthusiasm and high expectations toward my work. I am also very grateful to Dr. Ann
Fruhling who provided me with guidance on research methods in informatics, encouraged to submit a paper
to the international conference, and generously shared her knowledge in informatics. I thank Dr. Cheryl
Thompson who introduced me the world of health informatics and guided my course of study.
I thank Nebraska Medicine for supporting my education and career development. I am very
grateful to my colleagues in Nebraska Medicine who facilitated my work in different ways. I would like to
acknowledge Sue McQuade and Sue Miller who supported and encouraged me to strive for excellence in
my education and build my skills.
I have to recognize the support of my family. My dear sister Ivanna, thank you so much for your
love and words of kindness encouraging me to overcome many challenges. I am blessed to have my son
Vlad, my stepdaughters Erika and Aaren, and my niece Valeria who fill my life with great joy and
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admiration. My dear children, I am so proud of you and wish you always follow your dreams, help those in
need, and be strong no matter what!
My dear husband Brett, you are the one who witnessed the piles of my books, papers, and drafts. I
managed to finish this research because of your support. Thank you so much for your inspiration at the
most difficult times in this journey!
iii

ABSTRACT
IMPROVING ANTIBIOTIC RESISTANT INFECTION
TRANSMISSION SITUATIONAL AWARENESS IN ENCLOSED
FACILITIES WITH A NOVEL GRAPHICAL USER INTERFACE
FOR TACTICAL BIOSURVEILLANCE
Valeriya Kettelhut, Ph.D.
University of Nebraska Medical Center, 2015
Advisor: James McClay, M.D.
Serious challenges associated with antibiotic resistant infections (ABRIs) force healthcare
practitioners (HCPs) to seek innovative approaches that will slow the emergence of new ABRIs and
prevent their spread. It was realized that traditional approaches to infection prevention based on education,
retrospective reports, and biosurveillance often fail to ensure reliable compliance with infection prevention
guidelines and real-time problem solving. The objective of this original research was to develop and test the
conceptual design of a situational awareness (SA)-oriented information system for coping with healthcare-
associated infection transmission.
Constantly changing patterns in spatial distribution of patients, prevalence of infectious cases,
clustering of contacts, and frequency of contacts may compromise the effectiveness of infection prevention
and control in hospitals. It was hypothesized that providing HCPs with a graphical user interface (GUI) to
visualize spatial information on the risks of exposure to ABRIs would effectively increase HCPs‟ SA.
Increased SA may enhance biosurveillance and result in tactical decisions leading to better patient
outcomes. The study employed a mixed qualitative-quantitative research method encompassing
conceptualization of GUI content, transcription of electronic health record and biosurveillance data into
GUI visual artifacts, and evaluation of the GUI‟s impact on HCPs‟ perception and comprehension of the
conditions that increase the risk of ABRI transmission.
The study provided pilot evidence that visualization of spatial disease distribution and spatially-
linked exposures and interventions significantly increases HCPs‟ SA when compared to current practice.
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The research demonstrates that the SA-oriented GUI enables the HCPs to promptly answer the question,
“At a given location, what are the risks of infection transmission there?” This research provides a new form
of medical knowledge representation for spatial population-based decision-making within enclosed
environments. The next steps include rapid application development and further hypothesis testing
concerning the impact of this GUI on decsion-making.
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Table of Contents
ACKNOWLEDGEMENTS .............................................................................................................................i
ABSTRACT .................................................................................................................................................. iii
LIST OF ABBREVIATIONS ..................................................................................................................... viii
LIST OF TABLES .......................................................................................................................................... x
LIST OF FIGURES ........................................................................................................................................xi
LIST OF DIAGRAMS ................................................................................................................................ xiii
CHAPTER 1: CREATING OPPORTUNITIES FOR CONTAINMENT OF RESISTANT INFECTION
TRANSMISSION WITH INFORMATION TECHNOLOGIES ......................................................... 1
1.1. Challenges Associated with Antibiotic Resistance in Hospitals ............................................ 1
1.2. Role of Healthcare Information Technologies in Patient Outcomes ...................................... 4
1.3. User-Centered Design: Situational Awareness Oriented Approach ...................................... 7
1.4. Situational Awareness in the Healthcare Context ................................................................ 12
1.5. Research Study Objective, Hypothesis, and Aims ............................................................... 14
CHAPTER 2: GOAL SETTING AND TASK PERFORMANCE IN TEAMS ............................................ 17
2.1. Introduction ......................................................................................................................... 17
2.2. Impact of Hospital Environment on Health Care Performance ........................................... 17
2.3. The Goal Setting and Task Performance Theory Findings .................................................. 19
2.4. Goal-Performance Relationship at Individual Level: Micro Goals ..................................... 22
2.5. Goal-Performance Relationship at Organizational Level .................................................... 26
2.6. Linking Behavioral Theory and Situational Awareness-Oriented Interface Design ............ 29
2.7. Summary .............................................................................................................................. 31
CHAPTER 3: DEVELOPING THE RESISTANT INFECTION TRANSMISSION SITUATIONAL
AWARENESS CONCEPTUAL MODEL ......................................................................................... 32
3.1. Introduction ......................................................................................................................... 32
3.2. Study Objective, Design and Methods................................................................................. 32
3.3. Developing Critical Cues Depicting Nosocomial Infections Epidemiological Context ...... 33
vi

3.4. Summary .............................................................................................................................. 45
CHAPTER 4: INTEGRATING QUALITY INTO PRODUCT: DEVELOPING QUALITY
CONTEXTUAL FEATURES OF THE ANTIBIOTIC RESISTANT INFECTION
TRANSMISSION SITUATIONAL AWARENESS MODEL ........................................................... 46
4.1. Introduction ......................................................................................................................... 46
4.2. Part 1: Quality Management Knowledge ............................................................................. 46
4.3. Part 2: Exploration of Variations in the Unit Epidemiology ................................................ 57
4.4. Discussion ............................................................................................................................ 63
4.5. Summary .............................................................................................................................. 66
CHAPTER 5: APPLYING THE RULES OF IMAGE CONSTRUCTION TO VISUALIZATION OF THE
ABRITSA INFORMATION AS GROUNDWORK FOR A NOVEL GRAPHICAL USER
INTERFACE DESIGN FACILITATING TACTICAL BIOSURVEILLANCE ............................... 69
5.1. Introduction ......................................................................................................................... 69
5.2. Background: Effects of Data Representation on Human Performance ................................ 70
5.3. Image Theory ....................................................................................................................... 71
5.4. The Eye Physiology and Information Perception ................................................................ 72
5.5. Three Functions of Graphic Representation ........................................................................ 76
5.6. The Rules of Graphic Construction ..................................................................................... 78
5.7. Study Design and Methods .................................................................................................. 81
5.8. Transcribing the ABRITSA Information Set into Graphics ................................................ 83
5.9. Study Outputs ...................................................................................................................... 92
5.10. Discussion .......................................................................................................................... 93
5.11. Summary ............................................................................................................................ 94
CHAPTER 6: A QUASI-EXPERIMENTAL, PRE-POST EVALUATION OF THE NOVEL GRAPHICAL
INTERFACE DESIGN EFFECTS ON USERS‟ INFECTION PREVENTION SITUATION
AWARENESS .................................................................................................................................... 96
6.1. Introduction ......................................................................................................................... 96
vii

6.2. Background .......................................................................................................................... 98
6.3. A Theoretical Framework for Developing the ABRITSA Assessment Instrument ........... 101
6.4. Study Design and Methods ................................................................................................ 104
6.5. Developing a Simulated Event .......................................................................................... 106
6.6. A Pilot Validation of the Questionnaire, Training Materials, and the Graphical Interface 108
6.7. The Survey Process............................................................................................................ 110
6.8. Statistical Analysis............................................................................................................. 111
6.9. Results ............................................................................................................................... 113
6.10. Discussion ........................................................................................................................ 123
6.11. Study Contribution........................................................................................................... 128
6.12. Summary .......................................................................................................................... 129
CHAPTER 7: CLOSING REMARKS ........................................................................................................ 130
APPENDIX A: THE QUESTIONNAIRES ................................................................................................ 135
REFERENCES ............................................................................................................................................ 139
viii

LIST OF ABBREVIATIONS

ABR Antibiotic resistant
ABRIT Antibiotic resistant infection transmission
ABRITSA Antibiotic Resistant Infection Transmission Situational Awareness
ABRO Antibiotic resistant organism
C. difficile Clostridium difficile
CDC Centers for Disease Control and Prevention
CFIR Consolidated Framework for Implementation Research
CQHCA Committee on Quality of Health Care in America
CRE Carbapenem-resistant Enterobacteriaceae
CSE Cognitive Systems Engineering
DHHS The U.S. Department of Health and Human Services
EHR Electonic health record system
ESBL Extended-spectrum β-lactamase-producing Enterobacteriaceae
HAIs Healthcare-associated infections
HCPs Healthcare practitioners
HITECH Health Information Technology for Economic and Clinical Health Act
IOM The Institute of Medicine
IRB Institutional Research Board
IT Information technology
Level 1 SA First level of Situational Awareness
Level 2 SA Second level of Situational Awareness