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The recent FDA clearance of a device that
uses eye tracking to predict concussion (Brooks 2021) rekindled
our curiosity about use of eye tracking as a patient safety tool. The EYE-SYNC
technology includes neurocognitive batteries, symptom inventories, and
standardized patient inventories to identify the type and severity of
dysfunction after concussion. But the heart of the system is that it utilizes a
series of 60-second eye tracking assessments under virtual reality. A clinical study
showed that EYE-SYNC demonstrated sensitivity above 82% and specificity above
93%, for predicting concussion.
But our interest is in use of eye tracking methodologies to
identify fatigue in healthcare workers. Our many columns listed below have highlighted the role fatigue in
healthcare workers plays in medical errors and patient safety. We, ourselves,
are not very good at recognizing when we are already in the early throes of
fatigue. Hence, we need more objective methods of predicting and identifying
fatigue. Weve always suspected we will ultimately adopt technology as a means
to identify fatigue earlier. In our July 29, 2014 Patient Safety Tip of the
Week The 12-Hour Nursing Shift: Debate Continues we
predicted that someday we will have the equivalent of the brief sobriety or
breathalyzer test that can rapidly identify healthcare workers who are
impaired by fatigue. We might envision that at regular intervals beyond 8 hours
(maybe even sooner) or during periods of prolonged concentration the healthcare
worker will get buzzed on his/her smartphone and have to complete some simple
test of reaction times or attention span. If the worker scores outside the
established threshold the hospital will need to have resources in place to take
over duties of that worker (completely or at least temporarily until fatigue is
alleviated by, for example, a nap).
Well, eye tracking has the capability to be
that breathalyzer test equivalent and could potentially be performed in a
nonobtrusive manner. There are a variety of ocular phenomena that can be used
to detect early fatigue. In addition to eyelid drooping, alteration of saccadic
eye movements, number of fixations, fixation durations, changes in the blink
rate, and changes in pupillary responses may be early signs of fatigue.
Much
of the work on the relationship between eye movements and fatigue has been done
on people using computers. In healthcare, a logical specialty to analyze is the
radiologist. Radiologists often spend long periods at computer screens reading
various types of imaging. Our January
19, 2021 Patient Safety Tip of the Week Technology
to Identify Fatigue? discussed many of those studies involving
radiologists.
Of
course, other occupations where fatigue is a significant factor leading to
errors and accidents include airline pilot, bus driver, train engineer, etc.
There is probably more research ongoing to come up with ways to identify
fatigue in those occupations than in healthcare. Naeeri and colleagues (Naeeri
2021)
recently performed a multimodal analysis of eye movements and fatigue in a simulated
glass cockpit environment. The researchers first reviewed the literature on
methods of assessing pilot fatigue, including psychometric testing, various
physiologic testing, and eye tracking.
They
correlated eye tracking with results of psychometric vigilance tests (PVT) and
reaction times. The complicated regression models they used to assess the eye
tracking results are beyond the scope of our column. You can see them in the
Naeeri article itself, along with details of the psychomotor vigilance test
used and the equipment used to do the eye tracking, plus the various tasks and
procedures monitored in the pilots.
Obviously, it would take considerable engineering expertise to develop similar eye tracking assessment methods in various healthcare settings, but these could theoretically be used to help identify fatigue and loss of vigilance in real time. We can
The
subsequent question is what do you do with the results? If a healthcare
worker shows findings compatible with fatigue at the end of a first shift, you
would preclude overtime (or at least consider a rest period prior to any
overtime work). If a test performed, say 6 hours into a shift, shows findings
compatible with fatigue, you might consider an intervention such as a quick nap
(see our November 2012 What's New in
the Patient Safety World column The
Mid-Day Nap and
our September 6, 2016 Patient Safety Tip of the Week Napping Debate Rekindled).
For a radiologist, it might mean stepping away from the computer screen for a
specified period of time. Or for a pharmacist preparing and dispensing
medications, it might call for a brief rest break. But the dilemma becomes more
complicated if you were to identify signs of fatigue in a surgeon in the midst
of an operation.
We hope youll goo back to our January 19, 2021 Patient Safety Tip of the Week Technology to Identify Fatigue? for discussion of multiple studies using eye tracking technology in a variety of settings. This technology is a tool with great potential in healthcare and patient safety.
Some
of our other columns on the role of fatigue in Patient Safety:
November 9, 2010 12-Hour
Nursing Shifts and Patient Safety
April 26, 2011 Sleeping
Air Traffic Controllers: What About Healthcare?
February
2011 Update on 12-hour Nursing Shifts
September 2011 Shiftwork
and Patient Safety
November 2011 Restricted
Housestaff Work Hours and Patient Handoffs
January 2012 Joint
Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety
January 3, 2012 Unintended
Consequences of Restricted Housestaff Hours
June 2012
June
2012 Surgeon Fatigue
November 2012
The
Mid-Day Nap
November 13, 2012 The
12-Hour Nursing Shift: More Downsides
July 29, 2014
The
12-Hour Nursing Shift: Debate Continues
October 2014 Another
Rap on the 12-Hour Nursing Shift
December 2, 2014 ANA
Position Statement on Nurse Fatigue
August 2015 Surgical
Resident Duty Reform and Postoperative Outcomes
September 2015 Surgery
Previous Night Does Not Impact Attending Surgeon Next Day
September 29, 2015 More
on the 12-Hour Nursing Shift
September 6, 2016 Napping Debate Rekindled
April 18, 2017 Alarm Response and Nurse Shift Duration
July 11, 2017
The 12-Hour Shift Takes More Hits
February 13, 2018 Interruptions in the ED
April 2018 Radiologists Get Fatigued, Too
August 2018 Burnout and Medical Errors
September 4, 2018 The 12-Hour Nursing Shift: Another Nail in
the Coffin
August
2020 New Twist on Resident Work Hours and Patient
Safety
August
25, 2020 The
Off-Hours Effect in Radiology
September
2020 Daylight Savings Time Impacts Patient Safety?
January
19, 2021 Technology
to Identify Fatigue?
References:
Brooks
M. FDA Clears First Mobile Rapid Test for Concussion. Medscape Medical News
2021; October 05, 2021
https://www.medscape.com/viewarticle/960300
Naeeri
S. Kang Z. Mandal S. Kim K. Multimodal Analysis of Eye Movements and Fatigue in
a Simulated Glass Cockpit Environment. Aerospace 2021; 8: 283
https://www.mdpi.com/2226-4310/8/10/283
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