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17th International Conference on Naturalistic Decision Making

CTA in Effect: Case studies demonstrating the benefits of Cognitive Task Analysis

A Training to Recognize Sepsis in Children

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Primary Submitter:

Militello, Laura,


Healthcare: Sepsis recognition in children

Generic description of sponsoring organization or customer:

A children’s medical center that is an international leader in pediatric medicine, research, and education. The hospital has 652 pediatric beds and provides comprehensive pediatric care to patients aged 1-21. It is ranked third among all Honor Roll hospitals in 2019-20 U.S. News & World Report survey of best children’s hospitals. The pediatric resident training program is among the largest in the country, training approximately 200 physicians each year.

Cognitive Task Analysis Method(s):

Critical Decision Method (Crandall, et al., 2006)

Number of Participants:

We conducted 14 critical decision method (CDM) interviews with four novices (interns), four senior trainees (senior residents), and six faculty (expert) physicians. All faculty had completed a fellowship program and had been in the role of supervising physician for at least 5 years.


Training was developed and evaluated as part of a 3-year AHRQ grant, that included activities in addition to training development such as analysis of expert-novice differences, conference presentations, and journal publications. Cognitive task analysis took approximately 12 months, including training interviewers and analysis team, conducting interviews, and analyzing data. Training development and validation took approximately 12 months.


Sepsis Recognition Training Scenarios: The 14 interviews yielded 23 real-world incident accounts. Incident accounts were analyzed for cue recognition. Specifically, at least 2 individual analysts reviewed each incident and extracted cues that were described by the interviewee. They then met to reach consensus.

The result was a comprehensive list of cues noted in each case. Because capillary refill was identified as a particularly important cue that required judgment and was assessed in different ways, the analysis team created a critical cue inventory highlighting the range of cues described in assessing capillary refill. These findings were used to inform a set of 6 complementary training scenarios that combined sepsis-related
cues in a variety of contexts.

The scenarios were built into the hospital’s simulation facility using sophisticated manikins and confederates in the role of nurses, respiratory therapists, and other healthcare workers. The rich set of incidents and detailed discussion of cues in real-world contexts highlighted the “building block” cues relevant to sepsis that contemporary residents would experience rarely, if at all, during residency. As part of the sepsis-focused scenarios, one “garden path” scenario was developed to present a seemingly straightforward case of hypovolemia (severe dehydration due to vomiting and diarrhea), but as the scenario unfolds, additional information is presented that is not consistent with the initial working diagnosis. This method of scenario design contrasts common practice in simulation where scenarios are often based on a single near miss or adverse event as articulated during a root cause analysis. The set of scenarios developed in this project was designed to aid inexperienced physicians in understanding the range of ways in which sepsis might present, as well as highlight a relevant condition that could be easily confused with sepsis.

Demonstration of value:

We consider value in terms of: use, perceived benefit, and validation.

Use: The 6 sepsis scenarios became the foundation for medical center’s 3-year resident-focused,
simulation-based training curriculum. The initial scenarios were expanded to include other conditions, resulting in a curriculum with 24 different scenarios: 6 sepsis, 6 respiratory failure, 6 cardiopulmonary arrest, and 6 altered mental status. Within this curriculum, they currently run the sepsis scenarios in 45 two-hour sessions each year in a course called Resident Education Sessions Using Simulation (RESUS).

Perceived benefit: Faculty report that they feel the residents are better at recognizing sepsis due to this intervention. They also note that residents do not cover patients in all units (surgical units, units covered only by APRNs, etc.). As a result, some units did not receive the sepsis training until recently when a series of sepsis cases were missed:

“We recently had a series of missed sepsis cases in these units, so the hospital has gone “full force” to focus on this [sepsis]. Last year we ran a mandatory course for RNs and APRNs on one of these units, which was so successful we are being tasked with training for all RNs and APRNs. We are leveraging our previous and current work with the residents, but have expanded the training to include VR and in situ sessions to complement training in the lab. It is all built around sepsis recognition.”

Although we cannot know for certain, this series of events serves as a natural experiment, suggesting that units where residents were not exposed to the sepsis scenarios were more likely to miss sepsis – in fact this happened enough that the organization recognized it and implemented an intervention that included the CTA-derived sepsis scenarios. This is a strong indication that the organization values these scenarios and that they do indeed prepare physicians to recognize this life-threatening condition.

Validation: A validation study showed compelling evidence that experienced physicians were more likely to recognize sepsis in the simulated scenarios than residents – suggesting that the scenarios provided practice at thinking like an expert in realistic, challenging situations. Eighteen physicians participated in a 1-year validation study. Each physician completed 3 sepsis simulations in the simulation facility, while also being exposed to a simulation that was not sepsis. Sepsis was recognized in 19 (35%) of 54 simulations. The odds that experts recognized sepsis was 2.6 (95% CI 0.5, 13.8) times greater than novices. Adjusted for severity and level of expertise, the odds of recognizing sepsis was associated with an increase in the early sepsis management (ESM) checklist score of 1.8 (95% CI: 0.9, 3.6) and an increase in ESM global performance score of 4.1 (95% CI: 1.7, 10.0).


Used in the case study
Crandall, B., Klein, G., & Hoffman, R. R. (2006). Working minds. A practitioner’s guide to
cognitive task analysis. MIT Press.

Prior publication about this work

Geis, G. L., Wheeler, D. S., Bunger, A., Militello, L. G., Taylor, R. G., Bauer, J. P., Byczkowski,
T. L., Kerrey, B. T., & Patterson, M. D. (2018). A validation argument for a simulation-based training course centered on assessment, recognition and early management of pediatric sepsis. Simulation in Healthcare: Journal of the Society for Simulation in Healthcare, 13(1), 16-26.

Patterson, M. D., Militello, L. G., Bunger, A., Taylor, R. G., Wheeler, D. S., Klein, G., & Geis,
G. L. (2016). Leveraging the critical decision method to develop simulation-based
training for early recognition of sepsis. Journal of Cognitive Engineering and Decision
Making, 10(1), 36-56.