Emergency Physician Use of Cognitive Strategies to Manage Interruptions

The Big Three diagnostic errors through reflections of Japanese internists

OBJECTIVES

To analyze the Big Three diagnostic errors (malignant neoplasms, cardiovascular diseases, and infectious diseases) through internists' self-reflection on their most memorable diagnostic errors.

METHODS

This secondary analysis study, based on a web-based cross-sectional survey, recruited participants from January 21 to 31, 2019. The participants were asked to recall the most memorable diagnostic error cases in which they were primarily involved. We gathered data on internists' demographics, time to error recognition, and error location. Factors causing diagnostic errors included environmental conditions, information processing, and cognitive bias. Participants scored the significance of each contributing factor on a Likert scale (0, unimportant; 10, extremely important).

RESULTS

The Big Three comprised 54.1 % (n=372) of the 687 cases reviewed. The median physician age was 51.5 years (interquartile range, 42-58 years); 65.6 % of physicians worked in hospital settings. Delayed diagnoses were the most common among malignancies (n=64, 46 %). Diagnostic errors related to malignancy were frequent in general outpatient settings on weekdays and in the mornings and were not identified for several months following the event. Environmental factors often contributed to cardiovascular disease-related errors, which were typically identified within days in emergency departments, during night shifts, and on holidays. Information gathering and interpretation significantly impacted infectious disease diagnoses.

CONCLUSIONS

The Big Three accounted for the majority of cases recalled by Japanese internists. The most relevant contributing factors were different for each of the three categories. Addressing these errors may require a unique approach based on the disease associations.

Obstructive myocardial infarction with normal automated ECG interpretation: A case report

Emergency Medicine physicians experience a significant number of interruptions throughout their work day. One common cause of interruptions is the immediate interpretation of triage electrocardiograms (ECGs). Recent studies have suggested that ECGs interpreted as normal via automated analysis by the ECG machine rarely require urgent cardiac intervention and suggested that providers may not have to be interrupted to interpret these "normal" ECGs. We describe the case of a patient who presented to the Emergency Department (ED) with chest pain and an ECG interpreted as normal by an automated reading from the ECG machine, despite having acute coronary syndrome requiring emergent intervention.

Does the number of pages received per hour affect resident productivity?

Background

Workflow interruptions are common for emergency physicians and are shown to have downstream consequences such as patient dissatisfaction, delay in clinical response, and increase in medical error. However, the impact of passive interruptions on physician productivity is unclear and has not been well studied. We sought to evaluate if the number of pages received per hour significantly affects the number of patients seen per hour.

Methods

Retrospective data was collected on resident physician (RP) emergency department shifts from July 1st, 2021 to June 30th, 2022 at an academic medical center with an annual census of 55,000 patients. A total of 2865 RP shifts were collected among the 26 postgraduate year (PGY) 1 and PGY2 residents. For each RP shift, we identified the number of pages received per hour and the number of new patients seen per hour. Pages consist of any transmitted message that was sent to the RP's personal pager, which includes both automatic (eg, bed assignments, abnormal lab values) and personalized pages from other healthcare practicioners (eg, nursing, consultants). Data were analyzed using Poisson regression controlling for clustering at the physician level to determine if the number of patients seen per hour is significantly affected by the number of pages (divided into quartiles) received.

Results

We found the number of pages received per hour did not decrease the number of patients seen per hour. Contrary to our hypothesis, there was a strong positive relationship between the number of pages received per hour and the number of patients seen by RPs in that hour and subsequent hours. During the middle of a shift (hours 3, 4, and 5), RPs receiving pages in the third and fourth quartile (top 50% of pages) saw significantly more patients during that same hour and the next hour (p <0.001).

Conclusion

The number of pages received by RPs per hour did not decrease the number of patients seen per hour. When RPs receive a higher number of pages, there is a positive association with the number of patients they see in that hour and subsequent hours. Further studies will be needed to determine whether the content of pages affects resident productivity.

Shift Happens: Emergency Physician Perspectives on Fatigue and Shift Work

Research has shown that shiftworkers experience poor sleep and high levels of fatigue. Although considerable research has been performed on fatigue within many shift-work occupations, very little has been done with emergency physicians (EPs). This qualitative study was conducted with the goal of gaining insight into EPs' perceptions of fatigue at work. Twenty EPs from an academic medical center participated in virtual interviews, with nine open-ended questions asked in a semi-structured interview format. Twelve common topics with four main themes emerged from the interviews. Three of these common themes included sources of fatigue (including both work- and home-related sources), consequences of fatigue (including impacts on individuals and performance), and prevention and mitigation strategies to cope with fatigue. The fourth main theme was the belief in the inevitability of fatigue due to high cognitive load, emotionally taxing work experiences, work unpredictability, and the 24/7 shift-work nature of emergency medicine. EPs' experiences with fatigue are consistent with but extend those of other types of shiftworkers. Our findings suggest that EPs tend to incorporate the inevitability of fatigue at work into their identity as EPs and experience a sense of learned helplessness as a result, suggesting areas for future interventions.

Measuring Potential Visual Exposure of Physicians During Shift-End Handoffs and Its Impact on Interruptions, Privacy, and Collaboration

BACKGROUND

Frequent interruptions, inadequate privacy, and lack of collaboration are barriers to safe and efficient end-of-shift handoffs between emergency physicians. Varying levels of visibility to and from physicians can impact these outcomes. This study quantifies potential visual exposure of physicians in workstations with varying enclosure levels using isovist connectivity (IC) as a measure. Further, this study examines the association of IC with number of interruptions/hour, perceived collaboration, and privacy during handoffs.

METHODS

In-person observations were conducted during 60 handoffs to capture interruptions. Surveys were administered to the incoming and outgoing physicians to garner their perceptions of the extent of interruptions, collaboration, and privacy. Spatial analysis was conducted using DepthmapX.

RESULTS

Findings demonstrate significant differences in IC scores based on (a) physicians location within the workstation during; (b) handoff approach (individual or collaborative); (c) position during handoff (sitting or standing). Documented interruptions were highest in the high IC locations and lowest in the medium and low IC locations. Physicians in low IC locations perceived to have sufficient privacy to conduct handoffs.

LIMITATIONS AND CONCLUSION

It should be noted that the three pods, each housing a physician workstation with different enclosure levels, varied in number of patient rooms, patient acuity, overall size, and the location of workstations. While contextual variables were considered to the extent possible, several other factors could have resulted in differences in number of interruptions and collaboration levels. This study provides design recommendations for handoff locations and a method to test emergency physician workstation designs prior to construction.

Explaining emergency physicians' capacity to recover from interruptions

OBJECTIVE

To assess whether the capacity to utilize cues amongst emergency physicians is associated with differences in the capacity to recover performance following an interruption.

BACKGROUND

Interruptions are implicated in errors in emergency medicine due to the cognitive load that they impose on working memory, resulting in a loss of performance on the primary task. The utilization of cues is associated with a reduction in cognitive load during the performance of a task, thereby enabling the allocation of residual resources that mitigates the loss of performance following interruptions.

METHOD

Thirty-nine emergency physicians, recruited at a medical conference, completed an assessment of cue utilization (EXPERTise 2.0) and an online simulation (Septris) that involved the management of patients presenting with sepsis. During the simulation, physicians were interrupted and asked to check a medication order. Task performance was assessed using scores on Septris, with points awarded for the accurate management of patients.

RESULTS

Emergency physicians with higher cue utilization recorded significantly higher scores on the simulation task following the interruption, compared to physicians with lower cue utilization (p = .028).

CONCLUSION

The results confirm a relationship between cue utilization and the recovery of performance following an interruption. This is likely due to the advantages afforded by associated reductions in cognitive load.

APPLICATION

Assessments of cue utilization may assist in the development of interventions to support clinicians in interruptive environments.

How safe are paediatric emergency departments? A national prospective cohort study

BACKGROUND

Despite the high number of children treated in emergency departments, patient safety risks in this setting are not well quantified. Our objective was to estimate the risk and type of adverse events, as well as their preventability and severity, for children treated in a paediatric emergency department.

METHODS

Our prospective, multicentre cohort study enrolled children presenting for care during one of 168 8-hour study shifts across nine paediatric emergency departments. Our primary outcome was an adverse event within 21 days of enrolment which was related to care provided at the enrolment visit. We identified 'flagged outcomes' (such as hospital visits, worsening symptoms) through structured telephone interviews with patients and families over the 21 days following enrolment. We screened admitted patients' health records with a validated trigger tool. For patients with flags or triggers, three reviewers independently determined whether an adverse event occurred.

RESULTS

We enrolled 6376 children; 6015 (94%) had follow-up data. Enrolled children had a median age of 4.3 years (IQR 1.6-9.8 years). One hundred and seventy-nine children (3.0%, 95% CI 2.6% to 3.5%) had at least one adverse event. There were 187 adverse events in total; 143 (76.5%, 95% CI 68.9% to 82.7%) were deemed preventable. Management (n=98, 52.4%) and diagnostic issues (n=36, 19.3%) were the most common types of adverse events. Seventy-nine (42.2%) events resulted in a return emergency department visit; 24 (12.8%) resulted in hospital admission; and 3 (1.6%) resulted in transfer to a critical care unit.

CONCLUSION

In this large-scale study, 1 in 33 children treated in a paediatric emergency department experienced an adverse event related to the care they received there. The majority of events were preventable; most were related to management and diagnostic issues. Specific patient populations were at higher risk of adverse events. We identify opportunities for improvement in care.

Cognitive biases encountered by physicians in the emergency room

Background

Diagnostic errors constitute an important medical safety problem that needs improvement, and their frequency and severity are high in emergency room settings. Previous studies have suggested that diagnostic errors occur in 0.6-12% of first-time patients in the emergency room and that one or more cognitive factors are involved in 96% of these cases. This study aimed to identify the types of cognitive biases experienced by physicians in emergency rooms in Japan.

Methods

We conducted a questionnaire survey using Nikkei Medical Online (Internet) from January 21 to January 31, 2019. Of the 159,519 physicians registered with Nikkei Medical Online when the survey was administered, those who volunteered their most memorable diagnostic error cases in the emergency room participated in the study. EZR was used for the statistical analyses.

Results

A total of 387 physicians were included. The most common cognitive biases were overconfidence (22.5%), confirmation (21.2%), availability (12.4%), and anchoring (11.4%). Of the error cases, the top five most common initial diagnoses were upper gastrointestinal disease (22.7%), trauma (14.7%), cardiovascular disease (10.9%), respiratory disease (7.5%), and primary headache (6.5%). The corresponding final diagnoses for these errors were intestinal obstruction or peritonitis (27.3%), overlooked traumas (47.4%), other cardiovascular diseases (66.7%), cardiovascular disease (41.4%), and stroke (80%), respectively.

Conclusions

A comparison of the initial and final diagnoses of cases with diagnostic errors shows that there were more cases with diagnostic errors caused by overlooking another disease in the same organ or a disease in a closely related organ.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00708-3.

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.

Physician Flow at Work: Examining Work Absorption, Clinical Flow, Work Fulfillment, and Flow Thieves

BACKGROUND

The experience of "flow" at work correlates with positive job outputs and work-related attitudes. Very little current literature describes flow at work in physicians, who experience significant barriers to optimal work outputs, also known as flow thieves (e.g., case interruptions, documenting care). This study aimed to develop a measurement for physician flow (P-Flow) at work and examine the association of P-Flow with physician burnout, job satisfaction, and well-being.

METHODS

A pilot instrument was tested with items measuring P-Flow at work. After the pilot administration, a 14-item physician flow (P-Flow-14) scale was administered to physicians. In addition to the P-Flow-14 scale, physician respondents completed items measuring burnout, job satisfaction, and well-being.

RESULTS

This study specifies initial psychometric evidence of P-Flow-14 and 7-item P-Flow instruments for researchers interested in studying flow at work in physicians. For each P-Flow instrument, higher levels of the flow experience correlated with superior levels of well-being (p < .01) and job satisfaction (p < .01), and less burnout (p < .001). Results showed initial psychometric evidence of derived subscales (work absorption, clinical flow, flow thieves, work fulfillment) for application in future research. Results showed associations between flow experience by age group and physician specialty.

CONCLUSIONS/APPLICATION TO PRACTICE

To enhance well-being and job satisfaction, physicians should aim for concentration and immersion in clinical duties while reducing unnecessary distractions. These findings can be applied by employers and can guide further research on work interruptions and patient safety. Future research can validate the P-Flow scales and subscales to assess interventions aimed to improve the physician work environment.

Paediatric resident workflow observations in a community-based hospital

Objective

Residency graduates need to demonstrate competence in prioritising safe patient care through appropriate management of multiple competing tasks and workflow interruptions. This pilot study aimed to characterise and correlate interruptions in paediatric resident workflow at an academically affiliated, community-based hospital.

Methods

One of three trained observers followed a resident physician during a convenience sample of 1–2 hour increments, either in the emergency department or on the wards, and recorded all observed activities and interruptions using an established time-motion tool. All participants completed a baseline Multi-Tasking Ability Test (MTAT) and pre-observation and post-observation surveys. Statistical approach included descriptive statistics, logistic regression, mixed model and ORs.

Results

18 paediatric residents were observed for 57.5 total hours (an average of 3.2 hours/resident) which included 329 interruptions, defined as any external event drawing the resident’s attention away from a primary task. Interruptions occurred an average of 5.9 times per resident per hour. Interrupted primary tasks were not resumed during the observation period 11% of the time. A personal/social-related interruption yielded an OR of 0.29 that the resident will return to a primary task within 5 min (p=0.007) when compared with patient-related verbal interruptions by the medical team. The MTAT Score indicated decreased efficiency for interns versus postgraduate year 2 residents (p=0.029). Residents’ MTAT Scores did not correlate with their time to return to a primary task following an interruption (p=0.11).

Conclusions

Paediatric resident workflow interruptions in the hospital were observed to occur frequently and should be expected. Personal/social interruptions were most likely to delay prompt return to a primary task. The MTAT Score, although improved between the first 2 years of residency training, did not correlate with efficient return to a primary task. Interruption management and mitigation strategies should be developed as part of a standardised residency task management curriculum.

The Nature of Interruptions Among Inpatient Residents: a Time-Motion Observation-Based Mixed Methods Study

Interruptions are germane to inpatient medical practice but carry the consequences of reduced error prevention, psychological stress, and impaired knowledge consolidation among trainees. In this mixed methods study, we captured 172 task changes via time-motion observations of four residents on a general neurology service and completed semi-structured interviews with the same group. Twenty-five percent of task changes were due to interruptions, the majority via pager communications, and only 2% required urgent clinical attention. Residents reported frustration towards inefficient aspects of the pager system. Given the high rates of interruptions identified, we propose mitigating strategies such as triaging communications by urgency.

Interruptions to Intensive Care Nurses and Clinical Errors and Procedural Failures: A Controlled Study of Causal Connection

OBJECTIVES

Interruptions occur frequently in the intensive care unit (ICU) and are associated with errors. To date, no causal connection has been established between interruptions and errors in healthcare. It is important to know whether interruptions directly cause errors before implementing interventions designed to reduce interruptions in ICUs. The aim of the study was to investigate whether ICU nurses who receive a higher number of workplace interruptions commit more clinical errors and procedural failures than those who receive a lower number of interruptions.

METHODS

We conducted a prospective controlled trial in a high-fidelity ICU simulator. A volunteer sample of ICU nurses from a single unit prepared and administered intravenous medications for a patient manikin. Nurses received either 3 (n = 35) or 12 (n = 35) scenario-relevant interruptions and were allocated to either condition in an alternating fashion. Primary outcomes were the number of clinical errors and procedural failures committed by each nurse.

RESULTS

The rate ratio of clinical errors committed by nurses who received 12 interruptions compared with nurses who received 3 interruptions was 2.0 (95% confidence interval = 1.41-2.83, P < 0.001). The rate ratio of procedural failures committed by nurses who received 12 interruptions compared with nurses who were interrupted 3 times was 1.2 (95% confidence interval = 1.05-1.37, P = 0.006).

CONCLUSIONS

More workplace interruptions during medication preparation and administration lead to more clinical errors and procedural failures. Reducing the frequency of interruptions may reduce the number of errors committed; however, this should be balanced against important information that interruptions communicate.

Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department

BACKGROUND

Emergency physicians (EP) are frequently interrupted to screen electrocardiograms (ECG) from Emergency Department (ED) patients undergoing triage. Our objective was to identify discrepancies between the computer ECG interpretation and the cardiologist ECG interpretation and if any patients with normal ECGs underwent emergent cardiac intervention. We hypothesized that computer-interpreted normal ECGs do not require immediate review by an EP.

METHODS

This was a retrospective study of adult (≥ 18 years old) ED patients with computer-interpreted normal ECGs. Laboratory, diagnostic testing and clinical outcomes were abstracted following accepted methodologic guidelines. The primary outcome was emergent cardiac catheterization (within four hours of ED arrival). All ECGs underwent final cardiologist interpretation. When cardiology interpretation differed from the computer (discrepant ECG interpretation), the difference was classified as potentially clinically significant or not clinically significant. Data was described with simple descriptive statistics.

MAIN FINDINGS

989 ECGs interpreted as normal by the computer were analyzed with a mean age of 50.4 ± 16.8 years (range 18-96 years) and 527 (53%) female. Discrepant ECG interpretations were identified in 184 cases including 124 (12.5%, 95% CI 10.4, 14.7%) not clinically significant and 60 (6.1%, 95% CI 4.6, 7.7%) potentially clinically significant. The 60 potentially clinically significant changes included: ST/T wave changes 45 (75%), T wave inversions 6 (10%), prolonged QT 3 (5%), and possible ischemia 10 (17%). Of these 60, 21 (35%) patients were admitted. Six patients had potassium levels >6.0 mEq/L, with one having a potentially clinically significant ECG change. No patient (0%, 95% CI 0, 0.3%) underwent immediate (within four hours) cardiac catherization whereas two underwent delayed cardiac interventions.

CONCLUSIONS

Cardiologists frequently disagree with a computer-interpreted normal ECG. Patients with computer-interpreted normal ECGs, however, rarely had significant ischemic events. A rare number of patients will have important cardiac outcomes regardless of the computer-generated normal ECG interpretation. Immediate EP review of the ECG, however, would not have changed these patients' ED courses.

A novel approach: Simulating multiple simultaneous encounters to assess multitasking ability in emergency medicine

Study objective

The purpose of this feasibility study is to develop and validate a new assessment tool and scoring system for multitasking competency for physicians in-training in a timed simulated setting. The multitasking competency includes ability to appropriately prioritize and implement tasks for different patients who present simultaneously.

Methods

We designed three single task stations with different levels of difficulty and priority. These skill stations were then combined to create a multitasking simulation scenario. Skill checklists and the global rating scale were utilized to assess the participants’ performance. A multitasking score, multitasking index, and priority score were developed to measure the multitasking ability of participants.

Results

Thirty-three first-year postgraduate physicians were recruited for this prospective study. The total performance scores were significantly higher for the single-tasking stations than for the multitasking scenario. In terms of the time needed to complete the tasks, the participants spent more time on the multitasking scenario than on the single-tasking scenario. There were significant correlations between the global rating scale and the multitasking score (rho = 0.693, p < 0.001) and between the global rating scale and the multitasking index (rho = 0.515, p < 0.001). The multitasking score, multitasking index, and priority score did not have any significant correlations with the total single-tasking score.

Conclusion

We demonstrated that the use of a simulated multitasking scenario could be an effective method of assessing multitasking ability and allow assessors to offer better quality feedback.

Ischemic ECG Pattern Recognition to Facilitate Interpretation While Task Switching: A Parallel Curriculum

INTRODUCTION

Interruptions are an inevitable part of working as an emergency physician, yet these can increase cognitive load and precipitate medical error. Emergency physicians learn to balance these responsibilities using a process called task switching. Yet residents have little exposure to exercises that purposefully integrate task switching during their training. We addressed this gap by exposing emergency medicine (EM) trainees to task-switching events in the form of critical ECG interpretation while they were engaged in concurrent, parallel activities.

METHODS

The curriculum was carried out in three phases. First, 12 PGY 2 residents engaged in a small-group session testing their baseline confidence and ECG interpretation skills. The second phase was longitudinal: During concurrent educational activities, investigators interrupted tasks and asked trainees to interpret ECGs in 10 seconds or less. The curriculum's final phase was used to review the ECGs and answer any questions.

RESULTS

Confidence and percentage of correct interpretations were compared from phase 1 to phase 2. Participants showed improved confidence (M = 2.5, SD = 0.6, to M = 2.9, SD = 0.6; p = .02; 5-point Likert scale) and increased mean percent correct (M = 0.7, SD = 0.1, to M = 0.8, SD = 0.1; p = .01) following the curriculum.

DISCUSSION

Our curriculum provides a pragmatic, reproducible approach to enhancing critical ECG interpretation with task switching in a way that mirrors the EM practice environment, promoting a reduction of cognitive load and highlighting the skills learners will need as they develop expertise.

Evaluation of spin in the abstracts of emergency medicine systematic reviews and meta-analyses

INTRODUCTION

The objective of this study was to assess for spin - a form of reporting that overemphasizes benefits or downplay harms - within abstracts of systematic reviews and meta-analyses related to the clinical practice of emergency medicine (EM).

METHODS

PubMed was searched for systematic reviews and meta-analyses published since 2015 in either EM or general medical journals that examined an aspect of emergency medical care. In a duplicate, masked fashion, article titles and abstracts were screened to determine eligibility based on predetermined inclusion criteria. The included full-text studies were read and evaluated for spin using a previously determined search strategy. Two authors further evaluated study quality using the AMSTAR-2 tool.

RESULTS

Our PubMed search identified 478 systematic reviews and meta-analyses, of which a random sample of 200 was selected for data extraction. Spin within the abstract of the manuscript was identified in 34.5% (69/200) of the included reviews. We identified seven of the nine spin types, with two types being most common: (1) conclusion claiming a benefit despite high risk of bias among studies reviewed (19.5% of abstracts), and (2) conclusion claiming a benefit despite reporting bias (14.5%). No significant associations were found between the presence of spin and any of the evaluated study characteristics, the AMSTAR-2 appraisal, or the journal of publication.

CONCLUSION

Spin is commonly present in abstracts of EM systematic reviews. The reporting quality for EM systematic reviews requires improvement. Measures should be taken to improve the overall review process and way information is conveyed through abstracts.

Degree of interruptions experienced by emergency department nurses and interruption related factors

AIMS

This study examined the degree of interruptions experienced by emergency department nurses and related factors.

METHODS

This study is a descriptive survey using standardized observation tools. A total of 23 nurses working in an emergency department participated in this study. Using a stopwatch over 120 h, the degree of interruptions was investigated by measuring start and end times of tasks and interruptions. Factors related to interruptions were classified as communication, telephone calls, medical device alarms, changes in patient condition, and other factors.

RESULTS

The frequency of interruptions in the emergency department was 6.4 times per hour, and its percentage was 9.1%. The time required for actual nursing tasks of "counseling and education," "safety," and "patient nursing management and information management" were increased significantly due to interruptions. A primary factor in interruptions was communication with patients, families, and nurses. The longest duration and the highest frequency of interruptions occurred during medication tasks.

CONCLUSIONS

Communication with patients, families, and nurses was the highest factor related to interruptions. Nurses may cause interruptions and be subjected to interruptions simultaneously. Therefore, nurses in the emergency department should work with caution not to cause interruptions.

Nursing interruptions in emergency room in China: An observational study

AIM

To analyse the frequency and core elements of nursing work interruptions in Chinese emergency nursing settings.

BACKGROUND

Little is known about nursing interruptions, which affect the quality of services in Chinese emergency nursing setting.

METHOD(S)

A cross-sectional observational study was conducted in three units of an emergency department in a Chinese tertiary hospital. Participants comprised 60 nurses. Data were collected using a questionnaire developed by the researchers specifically for this study.

RESULTS

In total, 25,965 min of work was observed and 2333 interruptions were identified. Most interruptions were from patients, their families and nurses. Therapeutic nursing and patient observation and documentation were the most frequently interrupted procedures. Most interruptions were negative, and a majority of the nurses immediately responded to interruptions. Significant differences existed in the overall distribution of the core elements among the three nursing units.

CONCLUSIONS

The frequency of emergency nursing interruptions was moderate. Most interruptions tend to lead to negative treatment outcomes for patients.

IMPLICATIONS FOR NURSING MANAGEMENT

Emergency nursing managers should recognize the importance of interruptions, understand work situations better and develop ways to reduce the incidence of interruptions. Thus, nursing risks can be avoided by reducing the adverse outcomes caused by work interruptions.

A nationwide survey of emergency medicine resident workflow efficiency: Are training programs teaching residents to be efficient?

BACKGROUND

Workflow efficiency (WFE) is essential to the practice of emergency medicine (EM), but a standardized approach to measuring and teaching it during residency is lacking. In this study we sought to describe how EM residency programs in the United States currently measure and teach WFE and to assess the relative importance of WFE teaching to EM residency program leaders.

METHODS

We conducted a cross-sectional survey of all accredited EM residency training programs in the United States in Fall 2019. We invited all allopathic EM residency programs to participate in the study by directly emailing program directors and assistant/associate program directors. We conducted the study and performed descriptive statistics using SurveyMonkey software.

RESULTS

We received a total of 133 responses out of 190 total programs (70%) with proportionate representation from 3- and 4-year programs and all regions of the United States. When asked to what extent teaching efficiency should be a priority compared to other educational goals, 65% of program leaders responded with "significant" or "moderate" priority. Most EM programs collect WFE data on their residents, either by tracking patients per hour (78%) or by written evaluations (59%). Common methods for providing WFE data to residents were: "individual data provided along with deidentified rank" (35%), "data provided only during private feedback meetings" (26%), and "no data or rank provided to residents" (16%). Regarding targeted WFE teaching to residents, 88% reported utilizing general on-shift teaching, 48% reported teaching WFE during formal didactics, and 45% during dedicated private feedback sessions.

CONCLUSION

This national study of allopathic U.S. EM programs suggests that most EM program leaders do value WFE teaching. However, we found no consistent approach among programs for tracking or distributing resident WFE data, and many programs lack a formalized way to teach efficiency to their residents.

Emergency Physicians' Workstation Design: An Observational Study of Interruptions and Perception of Collaboration During Shift-End Handoffs

BACKGROUND

Frequent external interruptions and lack of collaboration among team members are known to be common barriers in end-of-shift handoffs between physicians in the emergency department. In spite of being the primary location for this crucial and cognitively demanding task, workstations are not designed to limit barriers and support handoffs.

OBJECTIVE

The purpose of this study is to examine handoff characteristics, actual and perceived interruptions, and perceived collaboration among emergency physicians performing end-of-shift handoffs in physician workstations with varying levels of enclosures-(a) open-plan workstation, (b) enclosed workstation, and (c) semi-open workstation.

METHOD

Handoff and interruption characteristics were captured through in-person observations of 60 handoffs using an iPad-based tool. Additionally, physicians participating in the handoffs responded to a survey pertaining to their perception of interruptions and collaboration with clinicians during each phase. Other organizational and demographic data were obtained from the hospital database, surveys, and observations.

RESULTS

Physicians working in the open workstation experienced a significantly higher number of interruptions/hour (18.08 int/hr) as compared to the semi-open (13.62 int/hr) and enclosed workstations (11.41 int/hr). Most physicians perceived that they were interrupted in the semi-open and open workstations. In addition, majority of physicians in the enclosed pod perceived high collaboration with clinicians involved in and present in the workstation during handoff.

CONCLUSION

This correlational study showed positive outcomes experienced by physician working in the enclosed workstation as compared to the open and semi-open workstations.

Quantifying Emergency Physician Interruptions due to Electrocardiogram Review

BACKGROUND

Interruptions are recognized as potentially harmful to safety and efficiency, and are especially prevalent in the emergency department (ED) setting. Policies urging immediate review of all electrocardiograms (ECGs) may lead to numerous and frequent interruptions.

OBJECTIVE

We assessed the role of ECG review as a source of ED interruptions to characterize a potential target for interventions.

METHODS

We analyzed emergency physician time use during the course of a clinical shift using a time-and-motion design. A research assistant observed a convenience sample of shifts, observing and logging transitions between different tasks using an electronic device. Instances of ECG review were tallied, with start and ending times of ECG review recorded to the nearest second. An ECG review was considered an interruption if the immediate prior and subsequent tasks were the same.

RESULTS

Twenty shifts were observed for a total of 149 h. There were 211 ECG reviews, (mean rate 1.4 per hour), with more frequent review among physicians staffing a zone with higher-acuity patients (2.8 per hour), where clustering of multiple ECG reviews in succession was more common. Seventy-five percent of ECG reviews required < 30 s. Of all 211 ECG reviews, 102 (48%) were an interruption. The tasks most frequently interrupted were electronic medical record system use (68 of 102, 67%) and communicating with ED staff in person (18 of 102, 18%).

CONCLUSIONS

Review of ECGs was a substantial driver of interruptions for emergency physicians. Interventions to integrate ECG review more naturally into physician workflow may improve patient safety by reducing these interruptions.

Multitasking behaviors and provider outcomes in emergency department physicians: two consecutive, observational and multi-source studies

Background

Multitasking is a key skill for emergency department (ED) providers. Yet, potentially beneficial or debilitating effects for provider functioning and cognition are underexplored. We therefore aimed to investigate the role of multitasking for ED physicians’ work stress and situation awareness (SA).

Methods

Two consecutive, multi-source studies utilizing standardized expert observations in combination with physicians’ self-reports on stress and SA were set out in an academic ED. To control for ED workload, measures of patient acuity, patient counts, and ED staff on duty were included. Regression analyses estimated associations between observed proportion of time spent in multitasking with matched ED physicians’ reports on stress (study 1) and SA (study 2).

Results

ED physicians engaged between 18.7% (study 1) and 13.0% (study 2) of their worktime in multitasking. Self-reported as well as expert-observed multitasking were significantly associated. This confirms the internal validity of our observational approach. After controlling for ED workload, we found that physicians who engaged more frequently in multitasking perceived higher work stress (Beta = .02, 95%CI .001–.03; p = .01). In study 2, ED physicians with more frequent multitasking behaviors reported higher SA (B = .08, 95%CI .02–.14; p = .009).

Conclusions

Multitasking is often unavoidable in ED care. Our findings suggest that ED physicians’ multitasking increases stress experiences, yet, may facilitate professional’s experiences of situation awareness. Our results warrant further investigation into potentially ambivalent effects of ED providers’ multitasking in effectively sharing time between competing demands while maintaining performance and safety.

Evaluation of Attention Switching and Duration of Electronic Inbox Work Among Primary Care Physicians

IMPORTANCE

Primary care physicians (PCPs) report multitasking during workdays while processing electronic inbox messages, but scant systematic information exists on attention switching and its correlates in the health care setting.

OBJECTIVES

To describe PCPs' frequency of attention switching associated with electronic inbox work, identify potentially modifiable factors associated with attention switching and inbox work duration, and compare the relative association of attention switching and other factors with inbox work duration.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of the work of 1275 PCPs in an integrated group serving 4.5 million patients used electronic health record (EHR) access logs from March 1 to 31, 2018, to evaluate PCPs' frequency of attention switching. Statistical analysis was performed from October 15, 2018, to August 28, 2020.

MAIN OUTCOMES AND MEASURES

Attention switching was defined as switching between the electronic inbox, other EHR work, and non-EHR periods. Inbox work duration included minutes spent on electronic inbox message views and related EHR tasks. Multivariable models controlled for the exposures.

RESULTS

The 1275 PCPs studied (721 women [56.5%]; mean [SD] age, 45.9 [8.5] years) had a mean (SD) of 9.0 (7.6) years of experience with the medical group and received a mean (SD) of 332.6 (148.3) (interquartile range, 252-418) new inbox messages weekly. On workdays, PCPs made a mean (SD) of 79.4 (21.8) attention switches associated with inbox work and did a mean (SD) 64.2 (18.7) minutes of inbox work over the course of 24 hours on workdays. In the model for attention switching, each additional patient secure message beyond the reference value was associated with 0.289 (95% CI, 0.217-0.362) additional switches, each additional results message was associated with 0.203 (95% CI, 0.127-0.278) additional switches, each additional request message was associated with 0.190 (95% CI, 0.124-0.257) additional switches, and each additional administrative message was associated with 0.262 (95% CI, 0.166-0.358) additional switches. Having a panel (a list of patients assigned to a primary care team) with more elderly patients (0.144 switches per percentage increase [95% CI, 0.009-0.278]) and higher inbox work duration (0.468 switches per additional minute of inbox work [95% CI, 0.411-0.524]) were also associated with higher attention switching involving the inbox. In the model for inbox work duration, each additional patient secure message beyond the reference value was associated with 0.151 (95% CI, 0.085-0.217) additional minutes, each additional results message was associated with 0.338 (95% CI, 0.272-0.404) additional minutes, each additional request message was associated with 0.101 (95% CI, 0.041-0.161) additional minutes, and each additional administrative message was associated with 0.179 (95% CI, 0.093-0.265) additional minutes. A higher percentage of the panel's patients initiating messages (0.386 minutes per percentage increase [95% CI, 0.026-0.745]) and attention switches (0.373 minutes per switch [95% CI, 0.328-0.419]) were also associated with higher inbox work duration. In addition, working at a medical center where all PCPs had high inbox work duration was independently associated with high or low inbox work duration.

CONCLUSIONS AND RELEVANCE

This study suggests that PCPs make frequent attention switches during workdays while processing electronic inbox messages. Message quantity was associated with both attention switching and inbox work duration. Physician and patient panel characteristics had less association with attention switching and inbox work duration. Assisting PCPs with message quantity might help modulate both attention switching and inbox work duration.

Health Information Technology–Related Wrong-Patient Errors: Context is Critical

Health information technology (HIT) provides many benefits, but also facilitates certain types of errors, such as wrong-patient errors in which one patient is mistaken for another. These errors can have serious patient safety consequences and there has been significant effort to mitigate the risk of these errors through national patient safety goals, in-depth research, and the development of safety toolkits. Nonetheless, these errors persist. We analyzed 1,189 patient safety event reports using a safety science and resilience engineering approach, which focuses on identifying processes to discover errors before they reach the patient so these processes can be expanded. We analyzed the general care processes in which wrong-patient errors occurred, the clinical process step during which the error occurred and was discovered, and whether the error reached the patient. For those errors that reached the patient, we analyzed the impact on the patient, and for those that did not reach the patient, we analyzed how the error was caught. Our results demonstrate that errors occurred across multiple general care process areas, with 24.4% of wrong-patient error events reaching the patient. Analysis of clinical process steps indicated that most errors occurred during ordering/prescribing (n=498; 41.9%) and most errors were discovered during review of information (n=286; 24.1%). Patients were primarily impacted by inappropriate medication administration (n=110; 37.9%) and the wrong test or procedure being performed (n=65; 22.4%). When errors were caught before reaching the patient, this was primarily because of nurses, technicians, or other healthcare staff (n=303; 60.5%). The differences between the general care processes can inform wrong-patient error risk mitigation strategies. Based on these analyses and the broader literature, this study offers recommendations for addressing wrong-patient errors using safety science and resilience engineering, and it provides a unique lens for evaluating HIT wrong-patient errors.

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.

SPRINT Through Tasks: A Novel Curriculum for Improving Resident Task Management in the Emergency Department

INTRODUCTION

The emergency department (ED) presents a challenging task-management environment to emergency medicine (EM) trainees. However, equipping residents with a tool to improve task switching (generically known as multitasking) could have positive impacts on patient care and physician emotional state. We designed a task-management tool and educational curriculum with the goal of improving emergency medicine resident task-switching ability.

METHODS

The task-management tool uses the acronym SPRINT: (1) stabilize critical patients, (2) perform procedures, (3) rack (see new patients in the chart rack), (4) in or out (reassess and disposition), (5) type it up (chart completion). These tasks and their order were decided on by two seasoned clinicians based on their years of experience in the ED. The SPRINT tool was taught to EM residents through a 1-hour curriculum consisting of an introductory video, a classroom-based workshop with multimedia didactics, and team learning with a card game simulating the use of the SPRINT tool on a shift. Residents were surveyed to evaluate their task-management confidence and perceived effectiveness of the curriculum.

RESULTS

A total of 34 EM residents participated in this training on the SPRINT tool. There was an improvement in resident confidence in task management, and residents reporting having a strategy for task prioritization 8 weeks after the workshop.

DISCUSSION

The SPRINT curriculum provides EM residents with a tool to manage the complex task-management environment of the ED. Further research in task-management education should focus on patient-oriented outcomes among physicians who have received this training.

Physicians' and nurses' work time allocation and workflow interruptions in emergency departments: a comparative time-motion study across two countries

BACKGROUND

Globally, emergency department (ED) work is fast-paced and subject to interruptions, placing high coordination and communication demands on staff. Our study aimed to compare ED staffs' work time allocation and interruption rates across professional roles and two national settings.

METHODS

We conducted a time-motion study with standardised expert observations of ED physicians and nurses in Germany and the USA. Observers coded ED staffs' activities and workflow interruptions. General and generalised linear models were used to examine differences in activities and interruption rates between countries and ED professions.

RESULTS

28 observations were conducted in the USA and 30 in Germany. Overall, the largest portion of time spent by ED staff in both settings was in documentation (22.0%). Physicians spent more time in verbal interaction with patients (9.9% vs 5.2% in nurses; p=0.006), in documentation (29.4% vs 15.6%; p<0.001) and other professional activities (13.0% vs 4.8%; p=0.002). Nurses allocated significantly more time to therapeutic (22.3% vs 6.0% in physicians; p<0.001) and organisational activities (20.4% vs 9.5%; p<0.001). Overall mean interruption rate per hour was 10.16 (US ED: 8.15, German ED: 12.04; p<0.001). American physicians and German nurses were most often disrupted by colleagues of the same profession (country: B=-.27, p=0.027; profession: B=0.35, p=0.006). German ED staff were interrupted more often by patients (B=-.78, p=0.001) and other sources (B=-.76, p<0.001) than American ED staff.

DISCUSSION

Our findings corroborate that professional roles largely determine time allocation to specific activities. However, interruption rates indicate differences between countries, suggesting the need for context-specific solutions to work stressors.

Changes to the ACGME Common Program Requirements and Their Potential Impact on Emergency Medicine Core Faculty Protected Time

The Accreditation Council for Graduate Medical Education (ACGME), which regulates residency and fellowship training in the United States, recently revised the minimum standards for all training programs. These standards are codified and published as the Common Program Requirements. Recent specific revisions, particularly removing the requirement ensuring protected time for core faculty, are poised to have a substantial impact on emergency medicine training programs. A group of representatives and relevant stakeholders from national emergency medicine (EM) organizations was convened to assess the potential effects of these changes on core faculty and the training of emergency physicians. We reviewed the literature and results of surveys conducted by EM organizations to examine the role of core faculty protected time. Faculty nonclinical activities contribute greatly to the academic missions of EM training programs. Protected time and reduced clinical hours allow core faculty to engage in education and research, which are two of the three core pillars of academic EM. Loss of core faculty protected time is expected to have detrimental impacts on training programs and on EM generally. We provide consensus recommendations regarding EM core faculty clinical work hour limitations to maintain protected time for educational activities and scholarship and preserve the quality of academic EM.

Getting Value From Electronic Health Records: Research Needed to Improve Practice

Electronic health records (EHRs) are now widely adopted in the United States, but health systems have barely begun using them to deliver high-value care. More directed and rigorous research is needed to fulfill the promise of EHRs to not only store information but also support the delivery of better care. This article describes 4 potential benefits of EHR-based research: improving clinical decisions, supporting triage decisions, enabling collaboration among the care team (including patients), and increasing productivity via automation of tasks. Six recommendations are made for conducting and reporting research to catalyze value creation: develop interventions systematically by using user-centered design and a building-block approach; assess value in terms of cost, quality, outcomes, and work required of providers and patients; consider the time horizon for the intervention; test best practices for implementation in a range of real-world contexts; assess subtleties of behavior change tools used to improve high-value behaviors; and report the intervention in enough detail that it can be replicated, including context. Just as research played a critical role in developing early EHR prototypes and demonstrating their value to justify dissemination, research will continue to be essential in the next phase: expanding EHR-based interventions and maximizing their role in creating value.

Varying rates of patient identity verification when using computerized provider order entry

OBJECTIVE

We sought to determine rates of computerized provider order entry (CPOE) patient identity verification and when and where in the ordering process verification occurred.

MATERIALS AND METHODS

Fifty-five physicians from 4 healthcare systems completed simulated patient scenarios using their respective CPOE system (Epic or Cerner). Eye movements were recorded and analyzed.

RESULTS

Across all participants patient id was verified significantly more often than not (62.4% vs 37.6%). Vendor A had significantly higher verification rates than not; vendor B had no difference. Participants using vendor A verified information significantly more often before signing the order than after (88.4% vs 11.6%); there was no difference in vendor B. The banner bar was the most frequent verification location.

DISCUSSION

Factors such as CPOE design, physician training, and the use of a simulated methodology may be impacting verification rates.

CONCLUSIONS

Verification rates vary by CPOE product, and this can have patient safety consequences.

Teaching Clinical Reasoning and Critical Thinking: From Cognitive Theory to Practical Application

Teaching clinical reasoning is challenging, particularly in the time-pressured and complicated environment of the ICU. Clinical reasoning is a complex process in which one identifies and prioritizes pertinent clinical data to develop a hypothesis and a plan to confirm or refute that hypothesis. Clinical reasoning is related to and dependent on critical thinking skills, which are defined as one's capacity to engage in higher cognitive skills such as analysis, synthesis, and self-reflection. This article reviews how an understanding of the cognitive psychological principles that contribute to effective clinical reasoning has led to strategies for teaching clinical reasoning in the ICU. With familiarity with System 1 and System 2 thinking, which represent intuitive vs analytical cognitive processing pathways, respectively, the clinical teacher can use this framework to identify cognitive patterns in clinical reasoning. In addition, the article describes how internal and external factors in the clinical environment can affect students' and trainees' clinical reasoning abilities, as well as their capacity to understand and incorporate strategies for effective critical thinking into their practice. Utilizing applicable cognitive psychological theory, the relevant literature on teaching clinical reasoning is reviewed, and specific strategies to effectively teach clinical reasoning and critical thinking in the ICU and other clinical settings are provided. Definitions, operational descriptions, and justifications for a variety of teaching interventions are discussed, including the "one-minute preceptor" model, the use of concept or mechanism maps, and cognitive de-biasing strategies.

Improving efficiency within a trauma nurse practitioner team

BACKGROUND

Clinicians, including nurse practitioners (NPs), face a number of challenges in delivering high-quality care including frequent interruptions that can potentially compromise patient safety and job satisfaction.

LOCAL PROBLEM

Trauma NPs voiced frustration with their efforts to provide efficient, high-quality care with frequent interruptions, most commonly pager alerts. The purpose of this quality improvement (QI) initiative was to increase trauma NPs' perceptions of patient safety and improve NPs' job satisfaction by reducing workflow interruptions.

METHODS

The Model for Improvement guided this initiative.

INTERVENTIONS

The aims of this initiative were to reduce the percentage of nonurgent workflow interruptions via pager alerts by 20% and to increase the utilization of a standardized trauma NP patient rounding process from 0% to 50%.

RESULTS

Use of the standardized rounding process improved from 0% to 87%. Interruptions via pager alerts decreased by 36.2%. All nine (100%) trauma NP survey responses revealed an improvement in NP perception of patient safety and job satisfaction.

CONCLUSION

The QI initiative found that increasing communication during rounds by using a standardized rounding process involving the bedside registered nurse can minimize interruptions and improve the efficiency of a trauma NP team. The key to the success of the QI initiative was the implementation of a standardized rounding process.

Wellness for the Future: Cultural and Systems-based Challenges and Solutions

The goal of the 2019 Society for Academic Emergency Medicine Consensus Conference was to explore the current cultural and systemic issues in emergency medicine that impact the individual well-being of every emergency physician and to make recommendations for future study. Burnout is epidemic in emergency medicine. Physician wellness is required to enhance patient clinical outcomes as well as to ensure professional satisfaction and longevity. For conference preparation, a consensus steering committee was created, and a decision was made to use the groundbreaking model of the National Academy of Medicine's "Factors Affecting Clinician Well-Being and Resilience" to further identify areas of needed study. On May 14, 2019, the Wellness Consensus Conference was attended by over 50 faculty physicians from across the United States. These attendees discussed key concepts and prior research presented by content experts. Groups of participants engaged in crowdsourcing techniques to consolidate ideas derived from those discussions. These consensus concepts were recorded and are presented within this article. A repetitive theme noted at the conference was the overwhelming effect of the system and organization factors on individual physician well-being. The concept of ongoing assessment of professional fulfillment over the life span of the emergency physician was felt to be crucial in guiding wellness and resilience interventions in a timely manner. Examining ways to enable physicians to flourish rather than experience burnout are strong future directions for study.

A Comparison of One- and Four-Open-Chart Access: No Change in Computerized Provider Order Entry Error Rates

OBJECTIVE

To assess changes in computerized provider order entry error rates among providers who with less than 24-hour notice were switched from four-chart access to one-chart-only access.

METHODS

An interrupted time series analysis of emergency medicine providers, hospitalists, and maternal child health providers was performed with pairwise comparison of computerized provider order entry error rates within and between specialties. This retrospective snapshot consisted of four phases. Phase 1 was the baseline 2 weeks where providers were privileged to work with up to four charts open. Phase 2 was the 2-week period where providers were limited to one-chart access. Phase 3 was the 2-week period where providers were returned to four-chart access. And phase 4 was a 2-week period 3 months following the end of phase 3.

RESULTS

Analysis of the overall and specialty-stratified cohorts revealed no statistically significant differences in median computerized provider order entry error rates across the four phases (Wilcoxon signed-rank test, α = 0.05). However, statistically significant differences in median computerized provider order entry error rates were detected between the three specialties within each phase of the study (Kruskal-Wallis, p < 0.001).

CONCLUSION

Allowing providers in select specialties to have access to four charts simultaneously does not increase their computerized provider order entry error rates. Significant differences in error rates between specialties suggest the need for further study of the use of standardized order sets, charting, and workflow variations.

Development and Evaluation of a Virtual Research Environment to Improve Quality of Care in Overcrowded Emergency Departments: Observational Study

BACKGROUND

Despite a wide range of literature on emergency department (ED) overcrowding, scientific knowledge on emergency physicians' cognitive processes coping with overcrowding is limited.

OBJECTIVE

This study aimed to develop and evaluate a virtual research environment that will allow us to study the effect of physicians' strategies and behaviors on quality of care in the context of ED overcrowding.

METHODS

A simulation-based observational study was conducted over two stages: the development of a simulation model and its evaluation. A research environment in emergency medicine combining virtual reality and simulated patients was designed and developed. Afterwards, 12 emergency physicians took part in simulation scenarios and had to manage 13 patients during a 2-hour period. The study outcome was the authenticity of the environment through realism, consistency, and mastering. The realism was the resemblance perceived by the participants between virtual and real ED. The consistency of the scenario and the participants' mastering of the environment was expected for 90% (12/13) of the participants.

RESULTS

The virtual ED was considered realistic with no significant difference from the real world with respect to facilities and resources, except for the length of time of procedures that was perceived to be shorter. A total of 100% (13/13) of participants deemed that patient information, decision making, and managing patient flow were similar to real clinical practice. The virtual environment was well-mastered by all participants over the course of the scenarios.

CONCLUSIONS

The new simulation tool, Virtual Research Environment in Emergency Medicine, has been successfully designed and developed. It has been assessed as perfectly authentic by emergency physicians compared with real EDs and thus offers another way to study human factors, quality of care, and patient safety in the context of ED overcrowding.

Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors: A Randomized Clinical Trial

IMPORTANCE

Recommendations in the United States suggest limiting the number of patient records displayed in an electronic health record (EHR) to 1 at a time, although little evidence supports this recommendation.

OBJECTIVE

To assess the risk of wrong-patient orders in an EHR configuration limiting clinicians to 1 record vs allowing up to 4 records opened concurrently.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial included 3356 clinicians at a large health system in New York and was conducted from October 2015 to April 2017 in emergency department, inpatient, and outpatient settings.

INTERVENTIONS

Clinicians were randomly assigned in a 1:1 ratio to an EHR configuration limiting to 1 patient record open at a time (restricted; n = 1669) or allowing up to 4 records open concurrently (unrestricted; n = 1687).

MAIN OUTCOMES AND MEASURES

The unit of analysis was the order session, a series of orders placed by a clinician for a single patient. The primary outcome was order sessions that included 1 or more wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder measure (an electronic query that identifies orders placed for a patient, retracted, and then reordered shortly thereafter by the same clinician for a different patient).

RESULTS

Among the 3356 clinicians who were randomized (mean [SD] age, 43.1 [12.5] years; mean [SD] experience at study site, 6.5 [6.0] years; 1894 females [56.4%]), all provided order data and were included in the analysis. The study included 12 140 298 orders, in 4 486 631 order sessions, placed for 543 490 patients. There was no significant difference in wrong-patient order sessions per 100 000 in the restricted vs unrestricted group, respectively, overall (90.7 vs 88.0; odds ratio [OR], 1.03 [95% CI, 0.90-1.20]; P = .60) or in any setting (ED: 157.8 vs 161.3, OR, 1.00 [95% CI, 0.83-1.20], P = .96; inpatient: 185.6 vs 185.1, OR, 0.99 [95% CI, 0.89-1.11]; P = .86; or outpatient: 7.9 vs 8.2, OR, 0.94 [95% CI, 0.70-1.28], P = .71). The effect did not differ among settings (P for interaction = .99). In the unrestricted group overall, 66.2% of the order sessions were completed with 1 record open, including 34.5% of ED, 53.7% of inpatient, and 83.4% of outpatient order sessions.

CONCLUSIONS AND RELEVANCE

A strategy that limited clinicians to 1 EHR patient record open compared with a strategy that allowed up to 4 records open concurrently did not reduce the proportion of wrong-patient order errors. However, clinicians in the unrestricted group placed most orders with a single record open, limiting the power of the study to determine whether reducing the number of records open when placing orders reduces the risk of wrong-patient order errors.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02876588.

The Impact of Phone Interruptions on the Quality of Simulated Medication Order Validation Using Eye Tracking: A Pilot Study

INTRODUCTION

Order validation is an important component of pharmacy services, where pharmacists review orders with a focus on error prevention. Interruptions are frequent and may contribute to a reduction in error detection, thus potential medication errors. However, studying such errors in practice is difficult. Simulation has potential to study these events.

METHODS

This was a pilot, simulation study. The primary objective was to determine the rate of medication error detection and the effect of interruptions on error detection during simulated validation. Secondary objectives included determining time to complete each prescription page. The scenario consisted of validating three handwritten medication order pages containing 12 orders and 17 errors, interrupted by three phone calls timed during one order for each page. Participants were categorized in groups: seniors and juniors (including residents). Simulation sessions were videotaped and eye tracking was used to assist in analysis.

RESULTS

Eight senior and five junior pharmacists were included in the analysis. There was a significant association between interruption and error detection (odds ratio = 0.149, 95% confidence interval = 0.042-0.525, P = 0.005). This association did not vary significantly between groups (P = 0.832). Juniors took more time to validate the first page (10 minutes 56 seconds vs. 6 minutes 42 seconds) but detected more errors (95% vs. 69%). However, all major errors were detected by all participants.

CONCLUSIONS

We observed an association between phone interruptions and a decrease in error detection during simulated validation. Simulation provides an opportunity to study order validation by pharmacists and may be a valuable teaching tool for pharmacists and pharmacy residents learning order validation.

Provider interruptions and patient perceptions of care: an observational study in the emergency department

BACKGROUND

Interruptions are endemic in healthcare work environments. Yet, they can have positive effects in some instances and negative in others, with their net effect on quality of care still poorly understood. We aimed to distinguish beneficial and detrimental forms of interruptions of emergency department (ED) providers using patients' perceptions of ED care as a quality measure.

METHODS

An observational design was established. The study setting was an interdisciplinary ED of an academic tertiary referral hospital. Frequencies of interruption sources and contents were identified in systematic expert observations of ED physicians and nurses. Concurrently, patients rated overall quality of care, ED organisation, patient information and waiting times using a standardised survey. Associations were assessed with hierarchical linear models controlling for daily ED workload. Regression results were adjusted for multiple testing. Additionally, analyses were computed for ED physicians and nurses, separately.

RESULTS

On 40 days, 160 expert observation sessions were conducted. 1418 patients were surveyed. Frequent interruptions initiated by patients were associated with higher overall quality of care and ED organisation. Interruptions relating to coordination activities were associated with improved ratings of ED waiting times. However, interruptions containing information on previous cases were associated with inferior ratings of ED organisation. Specifically for nurses, overall interruptions were associated with superior patient reports of waiting time.

CONCLUSIONS

Provider interruptions were differentially associated with patient perceptions of care. Whereas coordination-related and patient-initiated interruptions were beneficial to patient-perceived efficiency of ED operations, interruptions due to case-irrelevant communication were related to inferior patient ratings of ED organisation. The design of resilient healthcare systems requires a thorough consideration of beneficial and harmful effects of interruptions on providers' workflows and patient safety.

Understanding Emergency Medicine Physicians Multitasking Behaviors Around Interruptions

BACKGROUND

Interruptions can adversely impact human performance, particularly in fast-paced and high-risk environments such as the emergency department (ED). Understanding physician behaviors before, during, and after interruptions is important to the design and promotion of safe and effective workflow solutions. However, traditional human factors-based interruption models do not accurately reflect the complexities of real-world environments like the ED and may not capture multiple interruptions and multitasking.

METHODS

We present a more comprehensive framework for understanding interruptions that is composed of three phases, each with multiple levels: interruption start transition, interruption engagement, and interruption end transition. This three-phase framework is not constrained to discrete task transitions, providing a robust method to categorize multitasking behaviors around interruptions. We apply this framework in categorizing 457 interruption episodes.

RESULTS

A total of 457 interruption episodes were captured during 36 hours of observation. The interrupted task was immediately suspended 348 (76.1%) times. Participants engaged in new self-initiated tasks during the interrupting task 164 (35.9%) times and did not directly resume the interrupted task in 284 (62.1%) interruption episodes.

CONCLUSION

Using this framework provides a more detailed description of physician behaviors in complex environments. Understanding the different types of interruption and resumption patterns, which may have a different impact on performance, can support the design of interruption mitigation strategies.

Workflow interruptions and stress atwork: a mixed-methods study among physicians and nurses of a multidisciplinary emergency department

OBJECTIVES

Dealing with multiple workflow interruptions is a major challenge in emergency department (ED) work. This study aimed to establish a taxonomy of workflow interruptions that takes into account the content and purpose of interruptive communication. It further aimed to identify associations of workflow interruptions with ED professionals' work stress.

DESIGN

Combined data from expert observation sessions and concomitant self-evaluations of ED providers.

SETTING

ED of an academic community hospital in Germany.

PARTICIPANTS

Multidisciplinary sample of ED physicians and nurses. 77 matched observation sessions of interruptions and self-evaluations of work stress were obtained on 20 randomly selected days.

OUTCOME MEASURES

ED professionals' stress evaluations were based on standardised measures. ED workload data on patient load, patient acuity and staffing were included as control variables in regression analyses.

RESULTS

Overall mean rate was 7.51 interruptions/hour. Interruptions were most frequently caused by ED colleagues of another profession (27.1%; mean interruptions/hour rate: 2.04), by ED colleagues of the same profession (24.1%; 1.81) and by telephone/beeper (21%; 1.57). Concerning the contents of interruption events, interruptions most frequently occurred referring to a parallel case under care (30.3%, 2.07), concerning the current case (19.1%; 1.28), or related to coordination activities (18.2%, 1.24). Regression analyses revealed that interruptive communication related to parallel cases significantly increased ED providers' stress levels (β=0.24, P=0.03). This association remained significant after controlling for ED workload.

DISCUSSION

Interruptions that refer to parallel cases under care were associated with increased stress among ED physicians and nurses. Our approach to distinguish between sources and contents of interruptions contributes to an improved understanding of potential benefits and risks of workflow interruptions in ED work environments. Despite some limitations, our findings add to future research on the implications of interruptions for effective and safe patient care and work in complex and dynamic care environments.