Cognitive Properties of a Trauma Center Operating Room (OR) Whiteboard

Introduction: The OR Whiteboard is a key component for supporting the collaborative work of the OR team, yet little is known about the cognitive properties of such displays in the medical domain. The objectives of this study were to: 1) analyze and interpret the staff interactions with the Whiteboard displaying the OR schedule; 2) examine how the Whiteboard was used in a Trauma Center where team coordination needs are exacerbated due to emergency surgery and frequent schedule changes. Our hypothesis was that the Whiteboard function is complex, multi purpose,and is exploited by clinicians as a tool to promote distributed cognition.

Setting and Methods: The six OR suite is part of a busy trauma center (>6,000 admissions/year).Trauma patients are admitted to the 10‑bed trauma resuscitation unit situated on the same floor and adjoining the OR’ss, allowing recently admitted patients to be moved rapidly and emergently to the OR. One OR is constantly available for such a contingency. However, the majority of surgeries are non‑emergency or add‑on cases. The 12x4 foot Whiteboard holds magnetic strips on which patient names, location, identification number, and surgical procedure are recorded in erasable marker. The Board is divided into three sections. The front left section displays which patients are scheduled for surgery and the assigned OR.The second section holds the “add on” cases, and the far right section is used to hold magnetic nametags for all OR staff and a variety of indicator magnets. The Whiteboard is located at the intersection of the OR entrance and the TRU. The area is accessible to clinical, housekeeping, supply, patient transport, and administrative staff. With IRB approval, data were gathered by direct observation, interviewing, and photographs. Observations started at 6:30 a.m. and continued until the afternoon for twenty‑one days during which there were a variety of charge nurses and charge anesthesiologists, and differing numbers of emergency and add‑on cases. Notes were taken about who came to the Whiteboard,their interactions with the board and other people at the Whiteboard. Short interviews were conducted about the visitors’ purposes and views on the function of the Whiteboard.

Results: The Whiteboard was used for several purposes including: 1) storage ‑ the many simultaneously displayed objects (e.g., staff assignments, surgical procedure, patient/OR location, etc.) were used to store information. Positioning of the magnetic strips and markings (e.g., OR #) exploit this; 2) accessing ‑ simultaneous accessing facilitated face‑to‑face interactions by providing a common reference point; 3) representational aiding ‑ the exploitation of color(red magnetic strips for emergencies, white for elective, and blue for add‑on cases)size (small indicator magnets for infectious patients or name tags for staff),fonts, positioning (a diagonal strip across a room indicates cases on hold),and grouping (all orthopedic cases together) was used. This system was noted to immediately inform viewers about the current workload status of the OR and who was working; 4) processing ‑ although no computers were involved in the Whiteboard display, the distributed cognition was apparent to the charge personnel;5) flexibility for manipulation ‑ items on the Whiteboard could easily be moved to visualize potential, contingency, or actual plans to see how they would work.

Discussion: Public displays such as an OR Whiteboard are common coordinative tools used in many non‑medical settings. The users of the OR Whiteboard showed ingenuity to satisfy the need of distri buted cognition. Particular strengths lay in use of magnetic strips and tags to represent task activities, schedules, patient and transportation status. The artifacts allowed easy manipulation to match supply of staff for demands of patient cases to be completed. The OR Whiteboard was much more complex than might be considered from a superficial view of its function. The major limitation was that future workload status was not well displayed, and there was a lack of prediction of surgery duration, a feature that can be approximated with the assistance of computers. With the support of the OR Whiteboard, accurate and timely communication about the OR workload status and staffing is independent of face‑to‑face communication and time. Funded by NSF grant IIS‑9900406. We gratefully acknowledge contribution of Shock Trauma, Nursing, Surgery, and Anesthesiology staff.