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Fiscal Year: FY 2017  Task Last Updated:  01/24/2018 
PI Name: Ebert, Douglas  Ph.D. 
Project Title: Clinical Outcome Metrics for Optimization of Robust Training 
   
Division Name: Human Research 
Program/Discipline--
Element/Subdiscipline:
NSBRI--Smart Medical Systems and Technology Team 
 
Joint Agency Name:   TechPort:  No 
Human Research Program Elements: (1) ExMC:Exploration Medical Capabilities
Human Research Program Risks: (1) Medical:Risk of Adverse Health Outcomes & Decrements in Performance due to Inflight Medical Conditions (IRP Rev I)
Human Research Program Gaps: (1) Med05:We do not know how to train crew for medical decision making and medical skills to enable extended mission or autonomous operations (IRP Rev I)
 (2) Med08:We do not have quantified knowledge bases and modeling to estimate medical risk incurred on exploration missions (IRP Rev I)
Space Biology Element: None
Space Biology Cross-Element Discipline: None
Space Biology Special Category: None
PI Email: debert@wylehou.com  Fax:  281.212.1210 
PI Organization Type: NASA CENTER  Phone: 281.212.1243  
Organization Name: Wyle Laboratories, Inc./NASA Johnson Space Center 
PI Address 1: Wyle Science, Technology and Engineering 
PI Address 2: 316E 
PI Web Page:  
City: Houston  State: TX 
Zip Code: 77058  Congressional District:  36 
Comments:  
Project Type: GROUND  Solicitation:  2013 HERO NNJ13ZSA002N-Crew Health (FLAGSHIP & NSBRI) 
Start Date: 06/01/2014  End Date:  05/31/2017 
No. of Post Docs: No. of PhD Degrees: 
No. of PhD Candidates: No. of Master' Degrees: 
No. of Master's Candidates: No. of Bachelor's Degrees: 
No. of Bachelor's Candidates: Monitoring Center:  NSBRI 
Contact Monitor:   Contact Phone:   
Contact Email:  
Flight Program:  
Flight Assignment:

 

Key Personnel Changes/Previous PI:  
COI Name (Institution): Young, Millennia  Ph.D. ( Wyle Laboratories )
Cole, Richard  M.D. ( The University of Texas Medical Branch )
Kerstman, Eric  M.D. ( The University of Texas Medical Branch )
Byrne, Vicky  M.S. ( Lockheed Martin Astronautics )
Garcia, Kathleen  B.S. ( Wyle Integrated Sciences and Engineering Group )
Sargsyan, Ashot  M.D. ( Wyle Laboratories )
McGuire, Kerry  Ph.D. ( NASA Johnson Space Center )
Gibson, Charles   ( Wyle Integrated Sciences and Engineering Group ) 
Grant/Contract No.: NCC 9-58-SMST03801 
Performance Goal No.:  
Performance Goal Text:

 

Task Description: The substantially different profiles of human exploration missions beyond Low Earth Orbit pose many challenges for the design of their medical support systems. The success of inflight medical care (from diagnosis to emergency and non-emergency treatment) will depend on proper execution of respective medical procedures, which may be hindered by insufficient onboard expertise, asynchronous communications (time delays), and longer time lags between crew medical officer (CMO) training and actual mission medical operations. Thus, exploration missions would ideally be equipped for autonomous medical care. For extreme operational settings with limited resources such as a deep space-faring vehicle, it is critical to consider not only the immediate outcomes of procedures, but also the consequences of missed diagnoses or unsuccessful procedures that may affect the entire mission. This experiment was designed to address the above concerns by examining the clinical outcome differences between physicians and non-physicians through standardized simulation testing, in both near-term clinical metrics and long-term mission outcomes. In addition, the project sought to improve on CMO training.

The ultimate goal of the work was to address the Human Research Program's Exploration Medical Capability (ExMC) Risk of Adverse Health Outcomes & Decrements in Performance due to Inflight Medical Conditions. This project moves NASA closer to resolving the ExMC knowledge gap Med08: We do not have quantified knowledge bases and modeling to estimate medical risk incurred on exploration missions. The project also addresses two additional ExMC gaps and three gaps under the Human Factors and Behavioral Performance Element's Risk of Performance Errors Due to Training Deficiencies.

The experiment used a two-tier approach. The first tier examined raw clinical outcome metrics by evaluating the performance of both physicians and non-physicians in a medical simulation laboratory using specific medical procedures and conditions. The second tier examined the mission-long impacts of the procedural outcomes obtained in Tier 1. For tier one, the COMfORT team designed training protocols and a training and testing software tool in collaboration with Butler Graphics (Detroit, MI). In addition to four hands on medical procedure modules, the software includes a differential diagnosis exercise to evaluate the ability of participants to correctly diagnose and manage simulated medical conditions. Using clearly defined outcome metrics, these carefully crafted medical simulations were used to compare the success of procedure performance and diagnostic decision-making by physicians versus non-physicians. The simulated procedures were: fundoscopic examination, kidney/urinary ultrasound, endotracheal intubation with a laryngeal mask airway device, ultrasound-guided intravenous catheter insertion, and a differential diagnosis exercise. Test subjects were evaluated either at three, six, or nine months after their initial training to assess trends in their performance over time. Overall, success rates were higher and time to completion shorter for physicians than for non-physicians, but the differences were not as great as expected. Furthermore, we could not demonstrate a clear decline in their procedural success rates due to a detraining effect over the course of nine months, as we had originally hypothesized. This was likely due to the high effectiveness of the just-in-time (JIT) training tool that was available to all participants at all time points. This interpretation is supported by consistently high software usability ratings collected during each session. Despite extensive training and JIT guidance, physicians still did not perform flawlessly, revealing the danger of medical risk underestimation due to over-reliance on a physician that will not be always successful if not current and active in the given subspecialty or procedure.

In the second tier of the project, we used the outcomes of the four simulated procedures and the diagnostic exercise as input for a modified version of the NASA Integrated Medical Model (IMM) to analyze the effect of imperfectly performed individual procedures on overall clinical outcomes and the consequent mission impacts. A modified version of the IMM was created, which accommodated failed diagnoses and procedures. Laboratory simulation output became IMM input, with model results informing a novel set of outcome metrics to more accurately estimate the mission impact of medical procedure outcomes. IMM runs similarly demonstrated that physicians performing medical procedures resulted in lower risks of evacuation and loss of crew life (LOCL) over the course of several mission profiles, although the differences between physicians and non-physicians were not as great as expected. Both physicians and non-physicians resulted in higher risk than IMM currently estimates, due to the current IMM default of 100% successful diagnosis and treatment of infight medical conditions. The crew health index (CHI) varied with medical provider, but not substantially. Short- and long-term outcomes were used to 1) define differences between physician and non-physician CMOs, 2) refine the outcome metrics themselves, and 3) refine and validate our novel medical training products.

Comparison of physician and non-physician outcomes in both tiers directly addresses the value of including physician CMOs on Exploration missions. Novel training products were developed, refined, and validated to improve future medical outcomes and provide a practical training framework for multiple disciplines. In addition to these benefits, the IMM enhancements allow for the variable success of diagnostic and interventional procedures that will strengthen crew health predictions and may expose unidentified medical resource gaps.

 

Rationale for HRP Directed Research:

 

Research Impact/Earth Benefits: Through the analysis of performance (raw metrics) and modeling (long-term outcome metrics), this team has outlined the clinical outcomes when physician versus non-physician CMOs perform medical procedures. Training methods and materials have been validated and the staggered testing paradigm has informed questions about the rate of skills/knowledge decay when high quality just-in-time training materials are provided. Training materials for specific medical conditions and their associated treatment protocols have been updated based on the types of errors and usability issues that were discovered. Training products developed through this work are expected to serve as an advanced template for other training programs. A module providing expanded functionality has been added to the NASA Integrated Medical Model which will strengthen predictions for spaceflight mission impacts.

While NASA missions (particularly exploration class missions) have special requirements for medical training and knowledge retention, this is not a problem specific to spaceflight. The problem of maintaining the proficiency of minimally trained medical caregivers and the changing recommendations associated with this training (e.g., CPR training) are evidence of the need for more information in this area. Additionally, the rapidly expanding field of telemedicine is increasing the demand for effective means of teaching non-medically trained personal to assist with or perform medical tasks. This research has provided a set of refined metrics linking both short- and long-term clinical outcomes to training deficiencies. These metrics can easily transfer to the medical teaching arena and be applied to levels from medical schools to basic CPR classes and telemedicine. Further, this research has yielded refined procedural training products which can also be transferred to educational settings. These tools are expected to become a template for expanded use in medical as well as other types of technical training (terrestrial and space applications) and because of their intuitive nature are expected to become excellent outreach tools as well.

 

Task Progress: In the past year, the team has completed recruitment of all test subjects and completed all training and evaluation sessions (over 200 total sessions). From a total of 151 interest survey responses (65 physician and 86 non-physician), 67 operator subjects were recruited and completed their training, baseline, and retest sessions. The 3 month group included 10 physicians and 10 non-physicians, 6 month group included 12 physicians and 12 non-physicians, and the 9 month group included 12 physicians and 11 non-physicians. Only 3 subjects dropped from the study prior to completing the retest session (two physicians and one non-physician). The study also relied on a pool of 23 NASA Test Subject Screening (TSS) volunteers for the live patient portions of the evaluation sessions (fundoscopy and kidney/bladder ultrasound modules). Image quality analysis was completed for fundoscopy and ultrasound imagery, and all success metric and software use data has been compiled. Software acceptability and usability ratings have also been tabulated for presentation.

Our medical simulations were linked to Integrated Medical Model (IMM) conditions to provide a resource map for integration of our success metrics into IMM as input data. IMM code modifications were completed and tested. IMM runs were completed for lunar 21 day, International Space Station (ISS) 6 month, ISS 1 year, and 2.5 year Mars missions using current assumptions of 100% medical task performance, and both baseline and detrained performance data from our evaluations. Software user comments were compiled and potential software improvements were identified based on a balance of criticality and ease of implementation in the current software structure.

An updated version of the software was produced and is available online for demonstrations. A software User's Guide was also generated. Baseline session data was compiled and presented at Human Research Program Investigators Workshop (HRP IWS) 2017, and the team has provided project summary and software demonstration presentations at NSBRI (National Space Biomedical Research Institute) Headquarters (ATD), at the Exploration Medical Capability Forum, and also for the Human Factors and Behavioral Performance group at Johnson Space Center. Multiple future collaborative options are being pursued.

 

Bibliography Type: Description: (Last Updated: 03/03/2016) Show Cumulative Bibliography Listing
 
Download in PDF pdf     
Fiscal Year: FY 2016  Task Last Updated:  06/10/2016 
PI Name: Ebert, Douglas  Ph.D. 
Project Title: Clinical Outcome Metrics for Optimization of Robust Training 
   
Division Name: Human Research 
Program/Discipline--
Element/Subdiscipline:
NSBRI--Smart Medical Systems and Technology Team 
 
Joint Agency Name:   TechPort:  No 
Human Research Program Elements: (1) ExMC:Exploration Medical Capabilities
Human Research Program Risks: (1) Medical:Risk of Adverse Health Outcomes & Decrements in Performance due to Inflight Medical Conditions (IRP Rev I)
Human Research Program Gaps: (1) Med05:We do not know how to train crew for medical decision making and medical skills to enable extended mission or autonomous operations (IRP Rev I)
 (2) Med08:We do not have quantified knowledge bases and modeling to estimate medical risk incurred on exploration missions (IRP Rev I)
Space Biology Element: None
Space Biology Cross-Element Discipline: None
Space Biology Special Category: None
PI Email: debert@wylehou.com  Fax:  281.212.1210 
PI Organization Type: NASA CENTER  Phone: 281.212.1243  
Organization Name: Wyle Laboratories, Inc./NASA Johnson Space Center 
PI Address 1: Wyle Science, Technology and Engineering 
PI Address 2: 316E 
PI Web Page:  
City: Houston  State: TX 
Zip Code: 77058  Congressional District:  36 
Comments:  
Project Type: GROUND  Solicitation:  2013 HERO NNJ13ZSA002N-Crew Health (FLAGSHIP & NSBRI) 
Start Date: 06/01/2014  End Date:  05/31/2017 
No. of Post Docs: No. of PhD Degrees: 
No. of PhD Candidates: No. of Master' Degrees: 
No. of Master's Candidates: No. of Bachelor's Degrees: 
No. of Bachelor's Candidates: Monitoring Center:  NSBRI 
Contact Monitor:   Contact Phone:   
Contact Email:  
Flight Program:  
Flight Assignment:

 

Key Personnel Changes/Previous PI:  
COI Name (Institution): Young, Millennia   ( Wyle Laboratories, Inc. )
Cole, Richard  M.D. ( The University of Texas Medical Branch )
Kerstman, Eric  M.D. ( The University of Texas Medical Branch )
Byrne, Vicky   ( Lockheed Martin Astronautics )
Garcia, Kathleen   ( Wyle Integrated Sciences and Engineering Group )
Sargsyan, Ashot   ( Wyle Laboratories, Inc. )
McGuire, Kerry   ( NASA Johnson Space Center )
Gibson, Charles   ( Wyle Integrated Sciences and Engineering Group ) 
Grant/Contract No.: NCC 9-58-SMST03801 
Performance Goal No.:  
Performance Goal Text:

 

Task Description: The objective of this research is to develop clinical outcome metrics and training tools for physician and non-physician crew medical officers (CMOs) in support of likely medical conditions. Multiple assessment techniques will be employed, centered around medical simulation studies which occur in 3, 6, and 12-month intervals after initial training (fundoscopic examination, renal stone screening, ultrasound-guided IV insertion, intubation, and diagnostic activity). These studies will systematically compare clinical outcomes of simulations performed by physician and non-physician crew CMO analogs for short-term outcome metrics. To enhance our understanding of long-term implications of imperfectly performed medical procedures, outcomes will be used as input to a modified version of the NASA Integrated Medical Model (IMM). Short- and long-term outcomes will be used to 1) define differences between physician and non-physician CMOs, 2) refine the outcome metrics themselves, and 3) refine or develop novel medical training products. There are multiple challenges to crew health care during extended spaceflight. Medical procedure performance could be affected by asynchronous communications (time delays), inability to evacuate, and prolonged time from initial CMO training to actual mission medical operations (including emergency and non-emergency care, diagnosis, and treatment). Exploration mission crews would ideally be equipped for autonomous medical care. In extreme resource-limited environments such as spaceflight, it is critical to consider not only the immediate outcome for each procedure, but also the consequences of a missed diagnosis or improperly performed procedure that will endure for the entire mission.

A two-tiered approach will be used for this project. The first tier will examine the raw clinical outcome metrics by evaluating the performance of both physicians and non-physicians in a medical simulation laboratory with human test subjects and patient simulators to present the conditions and specific procedures being evaluated. The second tier will examine the mission-long impacts of procedural outcomes. A modified version of the IMM will be created which will accommodate diagnoses and procedures that are not 100% correct. Simulation output will become IMM input, with model results informing a novel set of outcome metrics which will demonstrate the true mission impact of medical procedure outcomes. Comparison of physician and non-physician outcomes in both tiers will directly address the value of including physician CMOs on Exploration missions. Based on results from both tiers, deficiencies in training procedures and tools will be identified, and training products refined to improve future outcomes.

Our multidisciplinary team includes physicians, medical trainers, remote guidance experts, imaging/technology specialists, and human factors experts. This research is expected to produce physician and non-physician clinical outcome metrics and medical condition training tools that will reduce the Human Research Program Exploration Medical Capabilities' Risk of Unacceptable Health and Mission Outcomes Due to Limitations of In-flight Medical Capabilities. In addition to these benefits, the IMM enhancements would allow for the variable success of diagnostic and interventional procedures that could strengthen crew health predictions and expose unidentified medical resource gaps.

 

Rationale for HRP Directed Research:

 

Research Impact/Earth Benefits: Through the analysis of performance (raw metrics) and modeling (long-term outcome metrics), this team expects to distinguish clinical outcomes when physician versus non-physician CMOs perform medical procedures. Training deficiencies will be identified for both groups, and the staggered testing paradigm will inform questions about the rate of skills/knowledge decay and provide data that will indicate when refresher training needs to be scheduled. Training materials for specific medical conditions and their associated treatment protocols will be updated based on types of errors or usability issues that are discovered. Training products developed through this work are expected to serve as an advanced template for other training programs. A module providing expanded functionality will be added to the NASA Integrated Medical Model which will strengthen predictions for spaceflight mission impacts. While NASA missions (particularly exploration class missions) have special requirements for medical training and knowledge retention, this is not a problem specific to spaceflight. The problem of maintaining the proficiency of minimally trained medical caregivers and the changing recommendations associated with this training (e.g., CPR training) are evidence of the need for more information in this area. Additionally, the rapidly expanding field of telemedicine is increasing the demand for effective means of teaching non-medically trained personal to assist with or perform medical tasks. This research is expected to provide a set of refined metrics to link both short- and long-term clinical outcomes to training deficiencies. These metrics can easily transfer to the medical teaching arena and be applied to levels from medical schools to basic CPR classes and telemedicine. Further, this research will yield refined procedural training products which can also be transferred to educational settings. These tools are expected to become a template for expanded use in medical training (terrestrial and space applications) and because of their intuitive nature are expected to become excellent outreach tools as well.

 

Task Progress: The team has worked closely with Butler Graphics to develop the just-in-time (JIT) training and testing software, which is a central component of this project. Procedural modules (fundoscopy, kidney/bladder ultrasound, ultrasound guided IV insertion, and intubation) have been fully assembled. The team has been performing practice activities using the nearly complete modules with novice users, serving several functions: 1) identify bugs and required, 2) refine setup and data collection procedures, and 3) provide training practice for team members. Users had helpful suggestions but have also commented on the ease of use and comprehensive nature of material in each module. Diagnostic and treatment module flow, logic, and structure are complete with only minor content additions required. The team had initially chosen to use two tablet devices for this module (guidance software built into the JIT software on one device, while a patient simulator app ran on another). However, the team has chosen to integrate both functions into a single application in order to 1) simplify use (such as importing vitals from the patient simulator to the guidance software), and 2) eliminate the need for a second device. The diagnostic and treatment module has proven a challenging task, but the product is exciting in appearance function. This has been a worthwhile effort due to its importance to the evaluations, and also because it provides a functioning example of a clinical decision support tool that NASA might choose to develop in support of exploratory missions.

Data collection spreadsheets are in their near-final form, including incorporation of output from the software's click-tracking function. The team has worked to streamline data collection and processing methods, resulting in the plan for three primary data sources: 1) live observation data, 2) click tracking and quiz answer data from the software, and 3) usability questionnaire data. Session video recording will aid with live observation and will also serve as a back-up source of data should observations not be clear or are missed during live observation. Morae monitoring software will also be employed, but will be considered a back-up data source and a potential resource for in-depth usability analysis.

Subjects have been recruited for the study and have been distributed into the three test groups. The study requires 30 physicians and 30 non-physician subjects, but we chose to recruit 34 of each to account for attrition during the test period. Recruitment of the trainee test pool progressed well, with over 80 non-physician (Masters or PhD level education) and almost 40 physician responses, providing an ample waiting list. Recruitment included a questionnaire including specialties, training, and practice of specific skills, age, and other factors. Using a custom block randomization code, subjects were balanced among the three test groups based on prioritized parameters.

 

Bibliography Type: Description: (Last Updated: 03/03/2016) Show Cumulative Bibliography Listing
 
Download in PDF pdf     
Fiscal Year: FY 2015  Task Last Updated:  07/16/2015 
PI Name: Ebert, Douglas  Ph.D. 
Project Title: Clinical Outcome Metrics for Optimization of Robust Training 
   
Division Name: Human Research 
Program/Discipline--
Element/Subdiscipline:
NSBRI--Smart Medical Systems and Technology Team 
 
Joint Agency Name:   TechPort:  No 
Human Research Program Elements: (1) ExMC:Exploration Medical Capabilities
Human Research Program Risks: (1) Medical:Risk of Adverse Health Outcomes & Decrements in Performance due to Inflight Medical Conditions (IRP Rev I)
Human Research Program Gaps: (1) Med05:We do not know how to train crew for medical decision making and medical skills to enable extended mission or autonomous operations (IRP Rev I)
 (2) Med08:We do not have quantified knowledge bases and modeling to estimate medical risk incurred on exploration missions (IRP Rev I)
Space Biology Element: None
Space Biology Cross-Element Discipline: None
Space Biology Special Category: None
PI Email: debert@wylehou.com  Fax:  281.212.1210 
PI Organization Type: NASA CENTER  Phone: 281.212.1243  
Organization Name: Wyle Laboratories, Inc./NASA Johnson Space Center 
PI Address 1: Wyle Science, Technology and Engineering 
PI Address 2: 316E 
PI Web Page:  
City: Houston  State: TX 
Zip Code: 77058  Congressional District:  36 
Comments:  
Project Type: GROUND  Solicitation:  2013 HERO NNJ13ZSA002N-Crew Health (FLAGSHIP & NSBRI) 
Start Date: 06/01/2014  End Date:  05/31/2017 
No. of Post Docs: No. of PhD Degrees: 
No. of PhD Candidates: No. of Master' Degrees: 
No. of Master's Candidates: No. of Bachelor's Degrees: 
No. of Bachelor's Candidates: Monitoring Center:  NSBRI 
Contact Monitor:   Contact Phone:   
Contact Email:  
Flight Program:  
Flight Assignment:

 

Key Personnel Changes/Previous PI:  
COI Name (Institution): Hurst, Victor   ( Wyle Laboratories, Inc. )
Foy, Millennia   ( Wyle Laboratories, Inc. )
Cole, Richard  M.D. ( The University of Texas Medical Branch )
Kerstman, Eric  M.D. ( The University of Texas Medical Branch )
Byrne, Vicky   ( Lockheed Martin Astronautics )
Garcia, Kathleen   ( Wyle Integrated Sciences and Engineering Group )
Sargsyan, Ashot   ( Wyle Laboratories, Inc. )
McGuire, Kerry   ( NASA Johnson Space Center )
Gibson, Charles   ( Wyle Integrated Sciences and Engineering Group ) 
Grant/Contract No.: NCC 9-58-SMST03801 
Performance Goal No.:  
Performance Goal Text:

 

Task Description: The objective of this research is to develop clinical outcome metrics and training tools for physician and non-physician crew medical officers (CMOs) in support of likely medical conditions. Multiple assessment techniques will be employed, centered around medical simulation studies which occur in 3, 6, and 12-month intervals after initial training (fundoscopic examination, renal stone screening, ultrasound-guided IV insertion, intubation, and diagnostic activity). These studies will systematically compare clinical outcomes of simulations performed by physician and non-physician crew medical officer (CMO) analogs for short-term outcome metrics. To enhance our understanding of long-term implications of imperfectly performed medical procedures, outcomes will be used as input to a modified version of the NASA Integrated Medical Model (IMM). Short- and long-term outcomes will be used to 1) define differences between physician and non-physician CMOs, 2) refine the outcome metrics themselves, and 3) refine or develop novel medical training products. There are multiple challenges to crew health care during extended spaceflight. Medical procedure performance could be affected by asynchronous communications (time delays), inability to evacuate, and prolonged time from initial CMO training to actual mission medical operations (including emergency and non-emergency care, diagnosis, and treatment). Exploration mission crews would ideally be equipped for autonomous medical care. In extreme resource-limited environments such as spaceflight, it is critical to consider not only the immediate outcome for each procedure, but also the consequences of a missed diagnosis or improperly performed procedure that will endure for the entire mission.

For the proposed research, a two-tiered approach will be used. The first tier will examine the raw clinical outcome metrics by evaluating the performance of both physicians and non-physicians in a medical simulation laboratory with human test subjects and patient simulators to present the conditions and specific procedures being evaluated. The second tier will examine the mission-long impacts of procedural outcomes. A modified version of the IMM will be created which will accommodate diagnoses and procedures that are not 100% correct. Simulation output will become IMM input, with model results informing a novel set of outcome metrics which will demonstrate the true mission impact of medical procedure outcomes. Comparison of physician and non-physician outcomes in both tiers will directly address the value of including physician CMOs on Exploration missions. Based on results from both tiers, deficiencies in training procedures and tools will be identified, and training products refined to improve future outcomes.

Our multidisciplinary team includes physicians, medical trainers, remote guidance experts, imaging/technology specialists, and human factors experts. This research is expected to produce physician and non-physician clinical outcome metrics and medical condition training tools that will reduce the Human Research Program Exploration Medical Capabilities' Risk of Unacceptable Health and Mission Outcomes Due to Limitations of In-flight Medical Capabilities. In addition to these benefits, the IMM enhancements would allow for the variable success of diagnostic and interventional procedures that could strengthen crew health predictions and expose unidentified medical resource gaps.

 

Rationale for HRP Directed Research:

 

Research Impact/Earth Benefits: Through the analysis of performance (raw metrics) and modeling (long-term outcome metrics), this team expects to distinguish clinical medical outcomes when physician versus non-physician CMOs perform procedures. Training deficiencies will be identified for both groups, and the staggered testing paradigm will inform questions about the rate of skills/knowledge decay and provide data as to when refresher training needs to be scheduled. Training materials for specific medical conditions and their associated treatment protocols will be updated based on types of errors or usability issues that are discovered. Training products developed through this work are expected to serve as an advanced template for other procedures. A module providing expanded functionality will be added to the Integrated Medical Model which will strengthen predictions for spaceflight mission impacts. While NASA missions (particularly exploration class missions) have special requirements for medical training and knowledge retention, this is not a problem specific to spaceflight. The problem of maintaining the proficiency of minimally trained medical caregivers and the changing recommendations associated with this training (e.g., CPR training) are evidence of the need for more information in this area. This research is expected to provide a set of refined metrics to link both short- and long-term clinical outcomes to training deficiencies. These metrics can easily transfer to the medical teaching arena and be applied to levels from medical schools to basic CPR classes. Further, this research will yield refined procedural training tools which can also be transferred to educational settings. These tools are expected to become a template for expanded use in medical training (terrestrial and space applications) and because of their intuitive nature are expected to become excellent outreach tools as well.

 

Task Progress: The team has spent considerable effort designing all five simulation testing modules to ensure that each has specifically identified and measurable elements, while preserving procedure flow. Modules have been streamlined to focus on testing the skill in question. Procedures are in near final form and translation into the just-in-time (JIT) training/testing software is underway. Recording of video content for software is scheduled for May 2015. Specific metrics for all modules have been defined. The approach has been refined to streamline data collection, management, analysis, and interpretation.

The study will generate large volumes of data requiring distillation into meaningful elements. Metrics have been divided into four categories: 1) the rollup metric (procedure successful?), 2) sub-metrics (procedure milestones), 3) time, and 4) subjective notation. A reasonable fundus camera choice was required for the fundoscopy module. Space Medicine trainers indicated that previous operational solutions were difficult to use, and current operational hardware was discontinued.

The team forged collaboration with UC (University of California) Berkeley to use their Optical CellScope, an iPhone 5 based fundoscope. The CellScope is simple to use, can be used for non-dilated exams in some subjects (important for study logistics), and is handheld. The team worked with the CellScope extensively and developed the required training and data handling procedures. Concepts and content for the diagnostic module were developed. Medical conditions and presentations were chosen for the training, baseline, and re-test cases to optimize training and equalize difficulty level. This module is a limited clinical decision support tool designed with a balance of guidance to the subject without making the medical judgment decision, providing insight into the medical decision making process. The team has chosen to use two tablet devices for the diagnostic module-- the guidance software will be built into the JIT software on one device, while a separate patient simulator app will run on another. The team has identified data collection techniques and designed technical solutions to collect all data elements. Based on experiences with synchronization and analysis of video recordings post-collection, the team has chosen to record test sessions using quad-screen recording (Epiphan Pearl). This will allow simultaneous recording of four video feeds, including two cabin views, the ultrasound or fundoscope, and the subjects' view via wireless forehead-mounted GoPro. In this manner real-time observations can be confidently tallied and recordings archived for further analysis. The team has also chosen to use Morae software to monitor JIT software use. Morae monitors all on-screen interaction, displaying and recording on a remote monitoring computer. The team has tested the software on multiple tablet/PC systems required for data collection. Click-tracking will be incorporated into JIT software.

 

Bibliography Type: Description: (Last Updated: 03/03/2016) Show Cumulative Bibliography Listing
 
Download in PDF pdf     
Fiscal Year: FY 2014  Task Last Updated:  10/17/2014 
PI Name: Ebert, Douglas  Ph.D. 
Project Title: Clinical Outcome Metrics for Optimization of Robust Training 
   
Division Name: Human Research 
Program/Discipline--
Element/Subdiscipline:
NSBRI--Smart Medical Systems and Technology Team 
 
Joint Agency Name:   TechPort:  No 
Human Research Program Elements: (1) ExMC:Exploration Medical Capabilities
Human Research Program Risks: (1) Medical:Risk of Adverse Health Outcomes & Decrements in Performance due to Inflight Medical Conditions (IRP Rev I)
Human Research Program Gaps: (1) Med05:We do not know how to train crew for medical decision making and medical skills to enable extended mission or autonomous operations (IRP Rev I)
 (2) Med08:We do not have quantified knowledge bases and modeling to estimate medical risk incurred on exploration missions (IRP Rev I)
Space Biology Element: None
Space Biology Cross-Element Discipline: None
Space Biology Special Category: None
PI Email: debert@wylehou.com  Fax:  281.212.1210 
PI Organization Type: NASA CENTER  Phone: 281.212.1243  
Organization Name: Wyle Laboratories, Inc./NASA Johnson Space Center 
PI Address 1: Wyle Science, Technology and Engineering 
PI Address 2: 316E 
PI Web Page:  
City: Houston  State: TX 
Zip Code: 77058  Congressional District:  36 
Comments:  
Project Type: GROUND  Solicitation:  2013 HERO NNJ13ZSA002N-Crew Health (FLAGSHIP & NSBRI) 
Start Date: 06/01/2014  End Date:  05/31/2017 
No. of Post Docs:   No. of PhD Degrees:   
No. of PhD Candidates:   No. of Master' Degrees:   
No. of Master's Candidates:   No. of Bachelor's Degrees:   
No. of Bachelor's Candidates:   Monitoring Center:  NSBRI 
Contact Monitor:   Contact Phone:   
Contact Email:  
Flight Program:  
Flight Assignment:

 

Key Personnel Changes/Previous PI:  
COI Name (Institution): Byrne, Vickie  M.S. ( Lockheed Martin )
Cole, Richard  M.D. ( Self )
Foy, Millennia  Ph.D. ( Wyle Laboratories, Inc. )
Hurst, Victor  Ph.D. ( Wyle Laboratories, Inc. )
Kerstman, Eric  M.D. ( Wyle Laboratories, Inc. ) 
Grant/Contract No.: NCC 9-58-SMST03801 
Performance Goal No.:  
Performance Goal Text:

 

Task Description: This proposal addresses the NASA Research Announcement Human Exploration Research Opportunities (HERO), NNJ13ZSA002N-NSBRI Appendix B, Smart Medical Systems and Technology Team assignment. The objective of this research is to develop clinical outcome metrics and training tools for physician and non-physician crew medical officers (CMOs) in support of likely medical conditions. Multiple assessment techniques will be employed, centered around medical simulation studies which occur in 3, 6, and 12-month intervals after initial training (e.g. intubation, fundoscopic examination). These studies will systematically compare clinical outcomes of simulations performed by physician and non-physician crew medical officer (CMO) analogs for short-term outcome metrics. To enhance our understanding of long-term implications of imperfectly performed medical procedures, outcomes will be used as input to a modified version of the NASA Integrated Medical Model (IMM). Short- and long-term outcomes will be used to 1) define differences between physician and non-physician CMOs, 2) refine the outcome metrics themselves, and 3) refine or develop novel medical training products.

There are multiple challenges to crew health care during extended spaceflight. Medical procedure performance could be affected by asynchronous communications (time delays), inability to evacuate, and prolonged time from initial CMO training to actual mission medical operations (including emergency and non-emergency care, diagnosis, and treatment). Exploration mission crews would ideally be equipped for autonomous medical care. In extreme resource-limited environments such as spaceflight, it is critical to consider not only the immediate outcome for each procedure, but also the consequences of a missed diagnosis or improperly performed procedure that will endure for the entire mission. For the proposed research, a two-tiered approach will be used. The first tier will examine the raw clinical outcome metrics by evaluating the performance of both physician and non-physicians in a medical simulation laboratory equipped with a human patient simulator (and other simulation tools as needed) to present the conditions and specific procedures being evaluated. The second tier will examine the mission-long impacts of procedural outcomes. A modified version of the IMM will be created which will accommodate diagnoses and procedures that are not 100% correct. Simulation output will become IMM input, with model results informing a novel set of outcome metrics which will demonstrate the true mission impact of medical procedure outcomes. Comparison of physician and non-physician outcomes in both tiers will directly address the value of including physician CMOs on Exploration missions. Based on results from both tiers, deficiencies in training procedures and tools will be identified, and training products refined to improve future outcomes. Our experienced multidisciplinary team includes physicians, medical trainers, remote guidance experts, and imaging/technology specialists, human factors experts, and a physician astronaut. The proposed research is expected to produce physician and non-physician clinical outcome metrics and medical condition training tools that will reduce the Human Research Program Exploration Medical Capabilities’ “Risk of Unacceptable Health and Mission Outcomes Due to Limitations of In-flight Medical Capabilities”. In addition to these benefits, the IMM enhancements would allow for the variable success of diagnostic and interventional procedures that could strengthen crew health predictions and expose unidentified medical resource gaps.

 

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Research Impact/Earth Benefits: 0

 

Task Progress: New project for FY2014.

 

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