Perceived vs. actual distractions in the emergency department

Systematic review of interruptions in the emergency department work environment

OBJECTIVE

The purpose of this systematic review is to describe the operationalization of interruptions measurement and to synthesize the evidence on the causes and consequences of interruptions in the emergency department (ED) work environment.

METHODS

This systematic review of studies explores the causes and consequences of interruptions in the ED. Of 2836 abstract/titles screened, 137 full-text articles were reviewed, and 44 articles met inclusion criteria of measuring ED interruptions.

RESULTS

All articles reported primary data collection, and most were cohort studies (n = 30, 68%). Conceptual or operational definitions of interruptions were included in 27 articles. Direct observation was the most common approach. In half of the studies, quantitative measures of interruptions in the ED were descriptive only, without measurements of interruptions' consequences. Twenty-two studies evaluated consequences, including workload, delays, satisfaction, and errors. Overall, relationships between ED interruptions and their causes and consequences are primarily derived from direct observation within large academic hospitals using heterogeneous definitions. Collective strengths of interruptions research in the ED include structured methods of naturalistic observation and definitions of interruptions derived from concept analysis. Limitations are conflicting and complex evaluations of consequences attributed to interruptions, including the predominance of descriptive reports characterizing interruptions without direct measurements of consequences.

CONCLUSIONS

The use of standardized definitions and measurements in interruptions research could contribute to measuring the impact and influence of interruptions on clinicians' productivity and efficiency as well as patients' outcomes, and thus provide a basis for intervention research.

Characterizing Multitasking and Workflow Fragmentation in Electronic Health Records among Emergency Department Clinicians: Using Time-Motion Data to Understand Documentation Burden

BACKGROUND

The impact of electronic health records (EHRs) in the emergency department (ED) remains mixed. Dynamic and unpredictable, the ED is highly vulnerable to workflow interruptions.

OBJECTIVES

The aim of the study is to understand multitasking and task fragmentation in the clinical workflow among ED clinicians using clinical information systems (CIS) through time-motion study (TMS) data, and inform their applications to more robust and generalizable measures of CIS-related documentation burden.

METHODS

Using TMS data collected among 15 clinicians in the ED, we investigated the role of documentation burden, multitasking (i.e., performing physical and communication tasks concurrently), and workflow fragmentation in the ED. We focused on CIS-related tasks, including EHRs.

RESULTS

We captured 5,061 tasks and 877 communications in 741 locations within the ED. Of the 58.7 total hours observed, 44.7% were spent on CIS-related tasks; nearly all CIS-related tasks focused on data-viewing and data-entering. Over one-fifth of CIS-related task time was spent on multitasking. The mean average duration among multitasked CIS-related tasks was shorter than non-multitasked CIS-related tasks (20.7 s vs. 30.1 s). Clinicians experienced 1.4 ± 0.9 task switches/min, which increased by one-third when multitasking. Although multitasking was associated with a significant increase in the average duration among data-entering tasks, there was no significant effect on data-viewing tasks. When engaged in CIS-related task switches, clinicians were more likely to return to the same CIS-related task at higher proportions while multitasking versus not multitasking.

CONCLUSION

Multitasking and workflow fragmentation may play a significant role in EHR documentation among ED clinicians, particularly among data-entering tasks. Understanding where and when multitasking and workflow fragmentation occurs is a crucial step to assessing potentially burdensome clinician tasks and mitigating risks to patient safety. These findings may guide future research on developing more scalable and generalizable measures of CIS-related documentation burden that do not necessitate direct observation techniques (e.g., EHR log files).

Emergency physicians' active patient queues over the course of a shift

OBJECTIVES

When emergency physicians see new patients in an ad libitum system, they see fewer patients as the shift progresses. However, it is unclear if this reflects a decreasing workload, as patient assessments often span many hours. We sought to investigate whether the size of a physician's queue of active patients similarly declines over a shift.

METHODS

Retrospective cohort study, conducted over two years in three community hospitals in the Northeastern United States, with 8 and 9-h shifts. Timestamps of all encounters were recorded electronically. Generalized estimating equations were constructed to predict the number of active patients a physician concurrently managed per hour.

RESULTS

We evaluated 64 physicians over a two-year period, with 9822 physician-shifts. Across all sites, physicians managed an increasing queue of active patients in the first several hours. This queue plateaued in the middle of the shift, declining in the final hours, independently of other factors. Physicians' queues of active patients increased slightly with greater volume and acuity, but did not affect the overall pattern of work. Similarly, working alone or with colleagues had little effect on the number of active patients managed.

CONCLUSIONS

Emergency physicians in an ad libitum system tend to see new patients until reaching a stable roster of active patients. This pattern may help explain why physicians see fewer new patients over the course of a shift, should be factored into models of throughput, and suggests new avenues for evaluating relationships between physician workload, patient safety, physicians' well-being, and the quality of care.

Workflow disruptions and provider situation awareness in acute care: An observational study with emergency department physicians and nurses

BACKGROUND

The fast-paced and rapidly changing environment of an Emergency Department (ED) requires providers to have a high level of situation awareness (SA). However, acute clinical care also encompasses a multitude of interruption-laden work processes that might degrade SA. It is therefore important to understand how frequent interruptions affect ED provider cognition in general and SA in particular.

OBJECTIVE

We aimed to examine how sources and contents of provider workflow interruptions influence situation awareness of ED physicians and nurses.

METHODS

This prospective, multi-method study combined standardized observations, self-reports of ED providers, and ED administrative data of staffing and patient load. Expert observers identified ED providers' workflow interruptions during 90min observation sessions. Afterwards, each provider reported perceived disruptiveness and situation awareness. Controlling for patient load, patient acuity and staffing, we conducted regression analyses to explore prospective associations between interruptions and provider outcomes.

RESULTS

During 74 observation sessions of overall 110h and 40min, we observed 1205 workflow interruptions (mean rate: 10.9 interruptions/hour). Provider situation awareness was fairly high (M = 7.10; scale 0-10) with no difference between ED physicians and nurses. After controlling for ED workload data, we observed that high rates of interruptions were associated with lower levels of situation awareness (β = -0.27). Further analyses revealed that particularly interruptions by telephone/beeper, technical malfunctions as well as interruptive communication related to completed cases were correlated to low SA.

DISCUSSION

This study in a naturalistic ED setting shows that ED physicians and nurses continuously cope with disruptions and interruptions. Our findings reveal that highly interruptive workflow environments impede providers' situation awareness. Moreover, it sheds light on specific sources and contents of interruptions that influence providers' SA in acute care.

CONCLUSION

Frequent workflow interruptions can degrade ED providers' situation awareness. A deeper understanding of how avoidable and unavoidable interruptions affect provider cognitions with particular focus on social and technology-related disruptions is required. Further emphasis should be placed on the effective application of work re-design in this context to foster safe and efficient patient care.

Emergency Department Operations: An Overview

Emergency department (ED) operations reflect the intersection of factors external and internal to the ED itself, with unique problems posed by community and academic environments. ED crowding is primarily caused by a lack of inpatient beds for patients admitted through the ED. Changes to front-end operations, such as point-of-care testing and putting physicians in triage, can yield benefits in throughput, but require individual cost analyses. Balancing physician workloads can lead to substantial improvements in throughput. Observation pathways can reduce crowding while maintaining safety. Physician and nurse well-being is an underappreciated topic within operations, and demands close attention and further research.

Information Management in the Emergency Department

Information management in the emergency department (ED) is a challenge for all providers. The volume of information required to care for each patient and to keep the ED functioning is immense. It must be managed through varying means of communication and in connection with ED information systems. Management of information in the ED is imperfect; different modes and methods of identification, interpretation, action, and communication can be beneficial or harmful to providers, patients, and departmental flow. This article reviews the state of information management in the ED and proposes recommendations to improve the management of information in the future.