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Penel N, Mailliez A, Pannier D, Ducrocq C. [Should we take into account the informational stress of the medical oncologist?]. Bull Cancer 2024; 111:222-227. [PMID: 38199834 DOI: 10.1016/j.bulcan.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/17/2023] [Indexed: 01/12/2024]
Abstract
Information overload, informational stress and its deleterious consequences constitute a subject of growing interest in the way of work. This is quite well documented among anesthesiologists. Studies have also been carried out on cancer patients or on the general public in terms of cancer prevention. After having defined the concepts and the consequences, we hypothesize the presence of informational stress among medical oncologists. We illustrate this hypothesis regarding adjuvant treatment of breast cancer. Specific studies (qualitative and quantitative ones) would be particularly interesting in oncology.
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Affiliation(s)
- Nicolas Penel
- Department of Medical Oncology, Centre Oscar-Lambret, Lille, France; ULR 2694 - Metrics : évaluation des technologies de santé et des pratiques médicales, CHU de Lille, University of Lille, Lille, France.
| | - Audrey Mailliez
- Department of Medical Oncology, Centre Oscar-Lambret, Lille, France
| | - Diane Pannier
- Department of Medical Oncology, Centre Oscar-Lambret, Lille, France
| | - Christophe Ducrocq
- Faculty of Psychology, CIREL - Education and Training Sciences, Interuniversity Center for Research in Education of Lille, Lille University, Villeneuve d'Ascq, France
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2
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Kalam S, Selden N, Haycock K, Lowe T, Skaggs H, Dinh VA. Evaluating the Effect of Nursing-Performed Point-of-Care Ultrasound on Septic Emergency Department Patients. Cureus 2023; 15:e40519. [PMID: 37461778 PMCID: PMC10350309 DOI: 10.7759/cureus.40519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 07/20/2023] Open
Abstract
Introduction Nursing-performed point-of-care ultrasound (NP-POCUS) studies have been performed on applications such as ultrasound-guided peripheral intravenous line placement and assessing bladder volume. However, research on the use of NP-POCUS in the management of septic patients remains limited. The purpose of this quality improvement study was to investigate how NP-POCUS could impact fluid treatment decisions affecting septic patients in the emergency department (ED) using a focused IVC and lung ultrasound protocol. Methods Nurses received standardized training in POCUS and performed inferior vena cava (IVC) and lung ultrasound scans on septic patients in the ED at predetermined intervals (hours: zero, three, and six). Based on their findings, they were asked to make recommendations on fluid management. Emergency physicians (EPs), both residents and attendings, are providing recommendations for fluid management without the use of ultrasound, which is being compared to the nurse-driven POCUS assessment of fluid management. EPs reviewed the NP-POCUS assessments of patient fluid status to determine nursing accuracy. Results A total of 104 patients were scanned, with a mean age of 60.7 years. EPs agreed with nursing ultrasound assessments in 99.1% of cases. Nursing ultrasound images changed management or increased physician confidence in current treatment plans 83.7% and 96.6% of the time, respectively. Before reviewing saved nursing ultrasound images, EPs underestimated fluid tolerance in 37.5% of cases, overestimated fluid tolerance in 26% of cases, and correctly estimated fluid tolerance (within 500 ml) in 36.5% of cases. Throughout resuscitation, IVCs became less collapsible, the number of cases with B-lines was essentially unchanged, and less fluid was recommended. Conclusion This study demonstrated that nurse-performed POCUS is feasible and may have a meaningful impact on how physicians manage septic patients in the emergency department.
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Affiliation(s)
- Sharmin Kalam
- Emergency Medicine, Loma Linda University Medical Center, Loma Linda, USA
| | | | - Korbin Haycock
- Emergency Medicine, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Tammy Lowe
- Nursing, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Heather Skaggs
- Nursing, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Vi Am Dinh
- Emergency Medicine, Loma Linda University Medical Center, Loma Linda, USA
- Internal Medicine, Division of Pulmonary and Critical Care, Loma Linda University Medical Center, Loma Linda, USA
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3
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Mobeen A, Shafiq M, Aziz MH, Mohsin MJ. Impact of workflow interruptions on baseline activities of the doctors working in the emergency department. BMJ Open Qual 2022; 11:bmjoq-2022-001813. [PMID: 36096543 PMCID: PMC9472165 DOI: 10.1136/bmjoq-2022-001813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 08/28/2022] [Indexed: 11/10/2022] Open
Abstract
Background Workflow interruptions are common in the emergency department (ED) of the hospitals for physicians, leading to an increased risk of errors. Purpose This study aims to understand the baseline activities of the ED doctors and how these are affected by workflow interruptions. Methods The study was conducted in two phases to collect the doctor’s perspective (through questionnaire survey) and observer’s perspective (through workflow observation study) about ED doctors’ baseline activities and workflow interruptions. Two different perspectives were obtained to make the insights clearer and more valuable. The point of view of the 223 doctors working in ED of the hospitals was recorded through a questionnaire survey. In the second phase, the observer’s point of view (authors) was obtained through a workflow observation study, and 13 doctors were observed for 160 hours. Results Direct communication with patients (37.1%) and ‘documentation and prescription’ (22.7%) were found to be the most frequent activities. The most common interruptions were visual and auditory distractions, rumination (mind-wandering) and intrusion (by co-workers). Also, the time consumed on indirect patient care (6.6%) was higher than direct patient care (4. 2%). Interruptions increase the chances of errors by making it hard for a doctor to resume a primary task after facing interruptions. Conclusion Interruptions increase the chances of errors and make it difficult for the doctors to resume primary tasks (after facing such incidents).
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Affiliation(s)
- Asyia Mobeen
- Industrial Engineering Department, University of Engineering and Technology, Taxila, Pakistan
| | - Muhammad Shafiq
- Department of Industrial Engineering and Management, University of the Punjab, Lahore, Pakistan
- Supply Chain and Project Management Center, University of the Punjab, Lahore, Pakistan
| | - Muhammad Haris Aziz
- Department of Mechanical Engineering, University of Sargodha, Sargodha, Punjab, Pakistan
| | - Muhammad Junaid Mohsin
- Industrial Engineering Department, University of Engineering and Technology, Taxila, Pakistan
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Danesh V, Sasangohar F, Kallberg AS, Kean EB, Brixey JJ, Johnson KD. Systematic review of interruptions in the emergency department work environment. Int Emerg Nurs 2022; 63:101175. [PMID: 35843150 DOI: 10.1016/j.ienj.2022.101175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/05/2022] [Accepted: 05/04/2022] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Valerie Danesh
- Center for Applied Health Research, Baylor Scott & White Health, 3500 Gaston Ave, Dallas, TX 75246, United States.
| | - Farzan Sasangohar
- Applied Cognitive Ergonomics Lab Texas, A&M University, Houston, TX, United States; Industrial and Systems Engineering, Texas A&M University, 4079 Emerging Technologies Building, 3131 TAMU, College Station, TX 77843, United States.
| | - Ann-Sofie Kallberg
- School of Health and Welfare, Dalarna University, Falun, Sweden; Department of Emergency Medicine, Falun Hospital, Dalarna University, SE-79188, Sweden.
| | - Emily B Kean
- University of Cincinnati, Health Sciences Library, 231 Albert Sabin Way, Cincinnati, OH 45267, United States.
| | - Juliana J Brixey
- Biomedical Informatics and Nursing, The University of Texas Health Science Center, 6901 Bertner Ave, Rm 629, Houston, TX 77030, United States.
| | - Kimberly D Johnson
- University of Cincinnati, College of Nursing, 234 Proctor Hall 3110 Vine St., Cincinnati, OH 45221, United States.
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5
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Zhu X, Hu Y, Wang L, Li D, Wu X, Xia S, Cheng S. An Observational Study of Physicians' Workflow Interruptions in Outpatient Departments in China. Front Public Health 2022; 10:884764. [PMID: 35757627 PMCID: PMC9215343 DOI: 10.3389/fpubh.2022.884764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background Workflow interruptions are frequent in hospital outpatient clinics. Eventually, not only reducing the work efficiency and quality, but also further threatening patient safety. Over the last 10–15 years, research on workflow interruptions in inpatient care has increased, but there is a lack of research on the interruptions in outpatient clinics. The present study aimed to study the differences in physicians' workflow interruptions among outpatient departments in the tertiary hospital in China. Methods In a tertiary hospital, a standardized observational study of 32 doctors' workflow in outpatient department of four typical clinical specialties was conducted. The record of workflow interruptions was based on a self-made observation instrument after verifying its reliability and validity. Linear regression methods were used to assess outpatient characteristics as predictors of the number of interruptions. The Kruskal-Wallis test was used to analyze the difference about the duration of interruptions among specialties, and the Chi-Square Test was used to examine the sources of interruptions among different specialties, to determine whether interruption source is associated with specialty. Results The number of patients was the significant independent predictor of the number of interruptions (p < 0.001). In terms of work tasks being interrupted, the highest interruption rate occurred when physicians were asking health history: 19.95 interruptions per hour. The distribution of interruption sources among the four clinical specialties were statistically different (X2 = 16.988, p = 0.049). Conclusion The findings indicate that physicians' workflow interruptions are connected with many contents in the work system. Further emphasis should be placed on the effective application of hospital management measures in an interrupted environment to promote a safe and efficiency outpatient care.
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Affiliation(s)
- Ximin Zhu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yinhuan Hu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liuming Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dehe Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoyue Wu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shixiao Xia
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Siyu Cheng
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Di Rocco JR, Kimata C, Barat M, Kodama S. Paediatric resident workflow observations in a community-based hospital. BMJ Open Qual 2022; 11:bmjoq-2021-001607. [PMID: 35241437 PMCID: PMC8896048 DOI: 10.1136/bmjoq-2021-001607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 02/20/2022] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Jennifer R Di Rocco
- Pediatrics, Kapi'olani Medical Center for Women and Children, Honolulu, Hawaii, USA .,Pediatrics, University of Hawai'i at Mānoa John A Burns School of Medicine, Honolulu, Hawaii, USA
| | - Chieko Kimata
- Patient Safety & Quality Services, Hawai'i Pacific Health, Honolulu, Hawaii, USA
| | - Masihullah Barat
- University of Hawai'i at Mānoa John A Burns School of Medicine, Honolulu, Hawaii, USA
| | - Samantha Kodama
- University of Hawai'i at Mānoa John A Burns School of Medicine, Honolulu, Hawaii, USA
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A Concern for Intraoperative Distractions and Interference: An Observational Study Identifying, Measuring, and Quantifying Both within the Operating Theatre. Surg Res Pract 2021; 2021:9910290. [PMID: 34931175 PMCID: PMC8684503 DOI: 10.1155/2021/9910290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 12/01/2021] [Indexed: 11/18/2022] Open
Abstract
Background Modern surgical research has broadened to include an interest into the investigation of surgical workflow. Rigorous analysis of the surgical process has a particular focus on distractions. Operating theatres are inherently full of distractions, many not pertinent to the surgical process. Distractions have the potential to increase surgeon stress, operative time, and complications. Our study aims to objectively identify, classify, and quantify distractions during the surgical process. Methods 46 general surgical procedures were observed within a tertiary Irish hospital between June 2019 and October 2019. An established observational tool was used to apply a structured observation to all operations. Additionally, a nine-point ordinal behaviourally anchor scoring scale was used to assign an interference level to each distraction. Results The total operative observation time was 4605 minutes (mean = 100.11 minutes, std. deviation: 45.6 minutes). Overall, 855 intraoperative distractions were coded. On average, 18.58 distractions were coded per operation (std. deviation: 6.649; range: 5–34), with 11.14 distractions occurring per hour. Entering/exiting (n = 380, 42.88%) and case irrelevant communication (n = 251, 28.32%) occurred most frequently. Disruption rate was highest within the first (n = 275, 32%) and fourth operative quartiles (n = 342, 41%). Highest interference rates were observed from equipment issue and procedural interruptions. Anaesthetists initiated CIC more frequently (2.72 per operation), compared to nurses (1.57) and surgeons (1.17). Conclusion Our results confirm that distractions are prevalent within the operating theatre. Distractions contribute to significant interferences of surgical workflow. Steps can be taken to reduce overall prevalence and interference level by drawing upon a systems-based perspective. However, due to the ubiquitous nature of distractions, surgeons may need to develop skills to help them resume interrupted primary tasks so as to negate the effects distraction has on surgical outcomes. Data for the above have been presented as conference abstract in 28th International Congress of the European Association for Endoscopic Surgery (EAES) Virtual Congress, 23–26 June 2020.
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Santomauro C, Powell M, Davis C, Liu D, Aitken LM, Sanderson P. Interruptions to Intensive Care Nurses and Clinical Errors and Procedural Failures: A Controlled Study of Causal Connection. J Patient Saf 2021; 17:e1433-e1440. [PMID: 30113425 DOI: 10.1097/pts.0000000000000528] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Gao J, Rae AJ, Dekker SWA. Intervening in Interruptions: What Exactly Is the Risk We Are Trying to Manage? J Patient Saf 2021; 17:e684-e688. [PMID: 28953051 DOI: 10.1097/pts.0000000000000429] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Interruptions are thought to be significantly associated with medication administration errors. Researchers have tried to reduce medication errors by decreasing or eliminating interruptions. In this article, we argue that interventions are often (perhaps unreflectively) based on one particular model of risk reduction-that of barriers placed between the source of risk and the object-to-be-protected. Well-intentioned interventions can lead to unanticipated effects because the assumptions created by the risk model are not critically examined. In this article, we review the barrier model and the assumptions it makes about risk and risk reduction/prevention, as well as the model's incompatibility with work in healthcare. We consider how these problems lead to interruptions interventions with unintended negative consequences. Then, we examine possible alternatives, viz organizing work for high reliability, preventing safety drift, and engineering resilience into the work activity. These all approach risks in different ways, and as such, propose interruptions interventions that are vastly different from interventions based on the barrier model. The purpose of this article is to encourage a different approach for designing interruptions interventions. Such reflection may help healthcare communities innovate beyond old, ineffective, and often counterproductive interventions to handle interruptions.
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Affiliation(s)
- Jonathan Gao
- From the Safety Science Innovation Laboratory, Griffith University, Nathan, Queensland, Australia
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10
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Schrepel C, Amick AE, Sayed M, Chipman AK. Ischemic ECG Pattern Recognition to Facilitate Interpretation While Task Switching: A Parallel Curriculum. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2021; 17:11182. [PMID: 34557588 PMCID: PMC8421424 DOI: 10.15766/mep_2374-8265.11182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/16/2021] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Caitlin Schrepel
- Acting Instructor, Department of Emergency Medicine, University of Washington School of Medicine
| | - Ashley E. Amick
- Acting Instructor, Department of Emergency Medicine and Internal Medicine, University of Washington School of Medicine
| | - Madeline Sayed
- Residency Education Manager, Department of Emergency Medicine, University of Washington School of Medicine
| | - Anne K. Chipman
- Assistant Professor and Assistant Program Director, Department of Emergency Medicine, University of Washington School of Medicine
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Klein RP, Velan G, Young N, Shetty A, Moscova M. Quality use of diagnostic imaging in trauma, and the impact on emergency medical practice-a retrospective clinical audit. Emerg Radiol 2021; 28:761-770. [PMID: 33638062 DOI: 10.1007/s10140-021-01921-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/21/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE The current study aimed to evaluate the appropriateness of the decisions made to order diagnostic imaging for emergency trauma patients. METHODS A retrospective audit of 642 clinical decisions for 370 non-consecutive trauma cases was conducted at a level 1 adult trauma centre. Radiographs and computed tomography investigations were compared for compliance with the American College of Radiology/European Society of Radiology (ACR/ESR) imaging guidelines. The non-compliant imaging orders were evaluated for the following medical officer ranks: Junior Medical Officer (JMO), Senior Resident Medical Officer (SRMO), Emergency Medicine Registrar (EMR) and Consultants/Career Medical Officer (CMO). The time of imaging order (day/evening or night shift), whether the imaging led to conservative or surgical patient management, and whether the imaging order decisions led to a change in the clinical management of the patient were also considered. RESULTS Non-compliance with the ACR/ESR guidelines was low. At least half of non-compliant decisions made by each level of medical officer resulted in a change in patient management. In total, 11 (65%), 25 (53%), 12 (63%) and 11 (52%) of non-compliant imaging orders placed by JMOs, SRMOs, EMRs and Consultants, respectively, resulted in change of patient management. JMOs and SRMOs ordered a significantly higher proportion of non-compliant imaging studies for conservatively managed patients in comparison to surgically managed patients. CONCLUSION This study highlighted that most non-compliant imaging orders benefited the patient.
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Affiliation(s)
- Robert Peter Klein
- Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Gary Velan
- Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Noel Young
- Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, 2052, Australia.,Department of Radiology, Westmead Hospital, Darcy Rd, Westmead, NSW, 2145, Australia
| | - Amith Shetty
- Department of Emergency Medicine, Westmead Hospital, Darcy Rd, Westmead, NSW, 2145, Australia
| | - Michelle Moscova
- Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, 2052, Australia.
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12
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Ioannides KLH, Brownstein DJ, Henreid AJ, Torbati SS, Berdahl CT. Quantifying Emergency Physician Interruptions due to Electrocardiogram Review. J Emerg Med 2021; 60:444-450. [PMID: 33414047 DOI: 10.1016/j.jemermed.2020.11.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/01/2020] [Accepted: 11/22/2020] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Kimon L H Ioannides
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California
| | - Daniel James Brownstein
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Andrew J Henreid
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sam S Torbati
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Carl T Berdahl
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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13
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Augenstein T, Schneider A, Wehler M, Weigl M. Multitasking behaviors and provider outcomes in emergency department physicians: two consecutive, observational and multi-source studies. Scand J Trauma Resusc Emerg Med 2021; 29:14. [PMID: 33413575 PMCID: PMC7792086 DOI: 10.1186/s13049-020-00824-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/13/2020] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Tobias Augenstein
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Ziemssenstrasse 1, 80336, Munich, Germany.,Department of Emergency Medicine and Department of General, Visceral and Trauma Surgery, Academic Hospital Porz am Rhein, Urbacher Weg 19, 51149, Cologne, Germany
| | - Anna Schneider
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Ziemssenstrasse 1, 80336, Munich, Germany.,Institute of Medical Sociology and Rehabilitation Science, Charité - Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Markus Wehler
- Department of Emergency Medicine and Department of Medicine IV, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Matthias Weigl
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Ziemssenstrasse 1, 80336, Munich, Germany. .,Institute for Patient Safety, University Hospital Bonn, Bonn, Germany.
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Weigl M, Catchpole K, Wehler M, Schneider A. Workflow disruptions and provider situation awareness in acute care: An observational study with emergency department physicians and nurses. APPLIED ERGONOMICS 2020; 88:103155. [PMID: 32678775 DOI: 10.1016/j.apergo.2020.103155] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 03/24/2020] [Accepted: 05/10/2020] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Matthias Weigl
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Ziemssenstrasse 1, 80336, Munich, Germany.
| | - Ken Catchpole
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, SC, USA
| | - Markus Wehler
- University Hospital Augsburg, Department of Emergency Medicine and Department of Medicine IV, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Anna Schneider
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Ziemssenstrasse 1, 80336, Munich, Germany; Institute of Medical Sociology and Rehabilitation Science, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
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15
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Barratt R, Wyer M, Hor SY, Gilbert GL. Medical interns' reflections on their training in use of personal protective equipment. BMC MEDICAL EDUCATION 2020; 20:328. [PMID: 32967669 PMCID: PMC7509499 DOI: 10.1186/s12909-020-02238-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/09/2020] [Indexed: 05/08/2023]
Abstract
BACKGROUND The current COVID-19 pandemic has demonstrated that personal protective equipment (PPE) is essential, to prevent the acquisition and transmission of infectious diseases, yet its use is often sub-optimal in the clinical setting. Training and education are important to ensure and sustain the safe and effective use of PPE by medical interns, but current methods are often inadequate in providing the relevant knowledge and skills. The purpose of this study was to explore medical graduates' experiences of the use of PPE and identify opportunities for improvement in education and training programmes, to improve occupational and patient safety. METHODS This study was undertaken in 2018 in a large tertiary-care teaching hospital in Sydney, Australia, to explore medical interns' self-reported experiences of PPE use, at the beginning of their internship. Reflexive groups were conducted immediately after theoretical and practical PPE training, during hospital orientation. Transcripts of recorded discussions were analysed, using a thematic approach that drew on the COM-B (capability, opportunity, motivation - behaviour) framework for behaviour. RESULTS 80% of 90 eligible graduates participated. Many interns had not previously received formal training in the specific skills required for optimal PPE use and had developed potentially unsafe habits. Their experiences as medical students in clinical areas contrasted sharply with recommended practice taught at hospital orientation and impacted on their ability to cultivate correct PPE use. CONCLUSIONS Undergraduate teaching should be consistent with best practice PPE use, and include practical training that embeds correct and safe practices.
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Affiliation(s)
- Ruth Barratt
- Centre for Infectious Diseases and Microbiology, Westmead Institute for Medical Research, 176 Hawkesbury Rd, Westmead, NSW 2145 Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW Australia
- Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
| | - Mary Wyer
- Centre for Infectious Diseases and Microbiology, Westmead Institute for Medical Research, 176 Hawkesbury Rd, Westmead, NSW 2145 Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW Australia
| | - Su-yin Hor
- Centre for Health Services Management, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Gwendolyn L. Gilbert
- Centre for Infectious Diseases and Microbiology, Westmead Institute for Medical Research, 176 Hawkesbury Rd, Westmead, NSW 2145 Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW Australia
- Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
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16
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Schneider A, Williams DJ, Kalynych C, Wehler M, Weigl M. Physicians' and nurses' work time allocation and workflow interruptions in emergency departments: a comparative time-motion study across two countries. Emerg Med J 2020; 38:263-268. [PMID: 32759349 DOI: 10.1136/emermed-2019-208508] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 11/22/2019] [Accepted: 03/03/2020] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Anna Schneider
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich, Germany .,Institute of Medical Sociology and Rehabilitation Science, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Deborah J Williams
- Department of Emergency Medicine, University of Florida, College of Medicine Jacksonville, Jacksonville, Florida, USA
| | - Colleen Kalynych
- Department of Emergency Medicine, University of Florida, College of Medicine Jacksonville, Jacksonville, Florida, USA
| | - Markus Wehler
- Department of Emergency Medicine and Department of Medicine IV, University Hospital Augsburg, Augsburg, Germany
| | - Matthias Weigl
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich, Germany
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Sbaffi L, Walton J, Blenkinsopp J, Walton G. Information Overload in Emergency Medicine Physicians: A Multisite Case Study Exploring the Causes, Impact, and Solutions in Four North England National Health Service Trusts. J Med Internet Res 2020; 22:e19126. [PMID: 32716313 PMCID: PMC7418008 DOI: 10.2196/19126] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 05/22/2020] [Accepted: 06/11/2020] [Indexed: 12/19/2022] Open
Abstract
Background Information overload is affecting modern society now more than ever because of the wide and increasing distribution of digital technologies. Social media, emails, and online communications among others infuse a sense of urgency as information must be read, produced, and exchanged almost instantaneously. Emergency medicine is a medical specialty that is particularly affected by information overload with consequences on patient care that are difficult to quantify and address. Understanding the current causes of medical information overload, their impact on patient care, and strategies to handle the inflow of constant information is crucial to alleviating stress and anxiety that is already crippling the profession. Objective This study aims to identify and evaluate the main causes and sources of medical information overload, as experienced by emergency medicine physicians in selected National Health Service (NHS) trusts in the United Kingdom. Methods This study used a quantitative, survey-based data collection approach including close- and open-ended questions. A web-based survey was distributed to emergency physicians to assess the impact of medical information overload on their jobs. In total, 101 valid responses were collected from 4 NHS trusts in north England. Descriptive statistics, principal component analysis, independent sample two-tailed t tests, and one-way between-group analysis of variance with post hoc tests were performed on the data. Open-ended questions were analyzed using thematic analysis to identify key topics. Results The vast majority of respondents agreed that information overload is a serious issue in emergency medicine, and it increases with time. The always available culture (mean 5.40, SD 1.56), email handling (mean 4.86, SD 1.80), and multidisciplinary communications (mean 4.51, SD 1.61) are the 3 main reasons leading to information overload. Due to this, emergency physicians experience guideline fatigue, stress and tension, longer working hours, and impaired decision making, among other issues. Aspects of information overload are also reported to have different impacts on physicians depending on demographic factors such as age, years spent in emergency medicine, and level of employment. Conclusions There is a serious concern regarding information overload in emergency medicine. Participants identified a considerable number of daily causes affecting their job, particularly the traditional culture of emergency departments being always available on the ward, exacerbated by email and other forms of communication necessary to maintain optimal, evidence-based practice standards. However, not all information is unwelcome, as physicians also need to stay updated with the latest guidelines on conditions and treatment, and communicate with larger medical teams to provide quality care.
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Affiliation(s)
- Laura Sbaffi
- Information School, University of Sheffield, Sheffield, United Kingdom
| | - James Walton
- Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - John Blenkinsopp
- North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, United Kingdom
| | - Graham Walton
- Centre for Information Management, Loughborough University, Loughborough, United Kingdom
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18
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Walter SR, Brown BM, Dunsmuir WT. Detecting changes in task length due to task‐switching in the presence of repeated length‐biased sampling. AUST NZ J STAT 2020. [DOI: 10.1111/anzs.12296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Scott R. Walter
- Centre for Health Systems and Safety Research Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University Sydney Australia
| | - Bruce M. Brown
- School of Mathematics and Statistics University of New South Wales Sydney Australia
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19
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Arunachalam SP, Asan O, Nestler DM, Heaton HA, Hellmich TR, Wutthisirisart P, Marisamy G, Pasupathy KS, Sir MY. Patient-Care Team Contact Patterns Impact Treatment Length of Stay in the Emergency Department. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:345-348. [PMID: 31945912 DOI: 10.1109/embc.2019.8857803] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Real-time location systems (RTLS) has found extensive application in the healthcare setting, that is shown to improve safety, save cost, and increase patient satisfaction. More specifically, some studies have shown the efficacy of RTLS leading to an improved workflow in the emergency department. However, due to substantial implementation costs of such technologies, hospital administrators show reluctance in RTLS adoption. Our previous preliminary studies with RFID data in the emergency department (ED) demonstrated for the first time the quantification of `patient alone time' and its relationship to outcomes such as 30-day hospitalization. In this study, we use ED RTLS data to analyze patient-care team contact time (PCTCT) and its relationship to the total treatment length of stay (LOS) in ED. An observational cohort study was performed in the ED using RTLS data from Jan 17 - Sep 17, 2017, which included a total of 51,697 patients. PCTCT within the first hour of a patient's placement in a treatment bed was calculated and its relationship to treatment LOS was analyzed while controlling for confounding factors affecting treatment LOS. Results show that treatment LOS is highly correlated with the ED crowding captured by the patient-perprovider ratio, negatively correlated to the physician and resident visit frequency, and positively correlated to nurse visit frequency. The results can inform designing new guidelines for ideal patient-care team interactions and be used to determine optimal ED staffing levels and care team composition for effective care delivery.
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20
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21
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Sanderson P, McCurdie T, Grundgeiger T. Interruptions in Health Care: Assessing Their Connection With Error and Patient Harm. HUMAN FACTORS 2019; 61:1025-1036. [PMID: 31469315 DOI: 10.1177/0018720819869115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE We address the problem of how researchers investigate the actual or potential causal connection between interruptions and medical errors, and whether interventions might reduce the potential for harm. BACKGROUND It is widely assumed that interruptions lead to errors and patient harm. However, many reviewers and authors have commented that there is not strong evidence for a causal connection. METHOD We introduce a framework of criteria for assessing how strongly evidence implies causality: the so-called Bradford Hill criteria. We then examine four key "metanarratives" of research into interruptions in health care-applied cognitive psychology, epidemiology, quality improvement, and cognitive systems engineering-and assess how each tradition has addressed the causal connection between interruptions and error. RESULTS Outcomes of applying the Bradford Hill criteria are that the applied cognitive psychology and epidemiology metanarratives address the causal connection relatively directly, whereas the quality improvement metanarrative merely assumes causality, and the cognitive systems engineering metanarrative either implicitly or explicitly questions the feasibility of finding a direct causal connection with harm. CONCLUSION The Bradford Hill criteria are useful for evaluating the existing literature on the relationship between interruptions in health care, clinical errors, and the potential for patient harm. In the future, more attention is needed to the issue of why interruptions usually do not lead to harm, and the implications for how we approach patient safety.
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Affiliation(s)
| | - Tara McCurdie
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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22
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Walter SR, Dunsmuir WTM, Westbrook JI. Inter-observer agreement and reliability assessment for observational studies of clinical work. J Biomed Inform 2019; 100:103317. [PMID: 31654801 DOI: 10.1016/j.jbi.2019.103317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 10/17/2019] [Accepted: 10/20/2019] [Indexed: 10/25/2022]
Abstract
Inter-observer agreement (IOA) is a key aspect of data quality in time-and-motion studies of clinical work. To date, such studies have used simple and ad hoc approaches for IOA assessment, often with minimal reporting of methodological details. The main methodological issues are how to align time-stamped task intervals that rarely have agreeing start and end times, and how to assess IOA for multiple nominal variables. We present a combination of methods that simultaneously addresses both these issues and provides a more appropriate measure by which to assess IOA for time-and-motion studies. The issue of alignment is addressed by converting task-level data into small time windows then aligning data from different observers by time. A method applicable to multivariate nominal data, the iota score, is then applied to the time-aligned data. We illustrate our approach by comparing iota scores to the mean of univariate Cohen's kappa scores through application of these measures to existing data from an observational study of emergency department physicians. While the two scores generated very similar results under certain conditions, iota was more resilient to sparse data issues. Our results suggest that iota applied to time windows considerably improves on previous methods used for IOA assessment in time-and-motion studies, and that Cohen's kappa and other univariate measures should not be considered the gold standard. Rather, there is an urgent need for ongoing explicit discussion of methodological issues and solutions to improve the ways in which data quality is assessed in time-and-motion studies in order to ensure the conclusions drawn from such studies are robust.
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Affiliation(s)
- Scott R Walter
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, 75 Talavera Road, North Ryde, NSW 2113, Australia.
| | - William T M Dunsmuir
- Department of Statistics, School of Mathematics and Statistics, University of New South Wales, The Red Centre, UNSW Australia, Sydney, NSW 2052, Australia.
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, 75 Talavera Road, North Ryde, NSW 2113, Australia.
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23
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Walter SR, Raban MZ, Westbrook JI. Visualising clinical work in the emergency department: Understanding interleaved patient management. APPLIED ERGONOMICS 2019; 79:45-53. [PMID: 31109461 DOI: 10.1016/j.apergo.2019.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 04/05/2019] [Accepted: 04/09/2019] [Indexed: 06/09/2023]
Abstract
We present a unique data visualisation approach, called workflow time charts, to illustrate the sequential and multi-dimensional nature of work in emergency departments. Using 40 h of data from direct observations of emergency physicians, we applied the charts to visualise patient-stratified physicians' work as a continuous temporal process, including distinguishing tasks of different types and representing external prompts (similar to interruptions) and multitasking performance. The charts showed frequent changes in the nature of observed activities, with interleaved multitasking a constant feature and external prompts often clustered in time. Evidence of seniority-related differences in work were apparent with consultants switching between more concurrent patients and receiving more frequent clinical prompts than junior physicians, illustrating their overseeing and advice-giving role. The ubiquity of interleaved multitasking suggests a need to focus on developing individual strategies to support frequent cognitive switching. Work that appears fragmented at physician level may form part of a flexible and robust system, rather than an error-prone set of isolated individual behaviours.
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Affiliation(s)
- Scott R Walter
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.
| | - Magdalena Z Raban
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.
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Göras C, Olin K, Unbeck M, Pukk-Härenstam K, Ehrenberg A, Tessma MK, Nilsson U, Ekstedt M. Tasks, multitasking and interruptions among the surgical team in an operating room: a prospective observational study. BMJ Open 2019; 9:e026410. [PMID: 31097486 PMCID: PMC6530509 DOI: 10.1136/bmjopen-2018-026410] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES The work context of the operating room (OR) is considered complex and dynamic with high cognitive demands. A multidimensional view of the complete preoperative and intraoperative work process of the surgical team in the OR has been sparsely described. The aim of this study was to describe the type and frequency of tasks, multitasking, interruptions and their causes during surgical procedures from a multidimensional perspective on the surgical team in the OR. DESIGN Prospective observational study using the Work Observation Method By Activity Timing tool. SETTING An OR department at a county hospital in Sweden. PARTICIPANTS OR nurses (ORNs) (n=10), registered nurse anaesthetists (RNAs) (n=8) and surgeons (n=9). RESULTS The type, frequency and time spent on specific tasks, multitasking and interruptions were measured. From a multidimensional view, the surgical team performed 64 tasks per hour. Communication represented almost half (45.7%) of all observed tasks. Concerning task time, direct care dominated the surgeons' and ORNs' intraoperative time, while in RNAs' work, it was intra-indirect care. In total, 48.2% of time was spent in multitasking and was most often observed in ORNs' and surgeons' work during communication. Interruptions occurred 3.0 per hour, and the largest proportion, 26.7%, was related to equipment. Interruptions were most commonly followed by professional communication. CONCLUSIONS The surgical team constantly dealt with multitasking and interruptions, both with potential impact on workflow and patient safety. Interruptions were commonly followed by professional communication, which may reflect the interactions and constant adaptations in a complex adaptive system. Future research should focus on understanding the complexity within the system, on the design of different work processes and on how teams meet the challenges of a complex adaptive system. TRIAL REGISTRATION NUMBER 2016/264.
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Affiliation(s)
- Camilla Göras
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Anaesthesia and Intensive Care Unit, Falu Hospital, Falun, Sweden
- Centre for Clinical Research, Falun, Dalarna, Sweden
| | - Karolina Olin
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Development Centre, Turku University Hospital, Turku, Finland
| | - Maria Unbeck
- Trauma and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Karin Pukk-Härenstam
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Paediatric Emergency Department, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Ehrenberg
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
| | - Mesfin Kassaye Tessma
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Ulrica Nilsson
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Mirjam Ekstedt
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- School of Health and Caring Sciences, Linneuniversitet, Kalmar, Sweden
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The potential impact of an electronic medication management system on safety‐critical prescribing errors in an emergency department. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Soares WE, Price LL, Prast B, Tarbox E, Mader TJ, Blanchard R. Accuracy Screening for ST Elevation Myocardial Infarction in a Task-switching Simulation. West J Emerg Med 2019; 20:177-184. [PMID: 30643622 PMCID: PMC6324702 DOI: 10.5811/westjem.2018.10.39962] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/04/2018] [Accepted: 10/30/2018] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Interruptions in the emergency department (ED) are associated with clinical errors, yet are important when providing care to multiple patients. Screening triage electrocardiograms (ECG) for ST-segment elevation myocardial infarction (STEMI) represent a critical interrupting task that emergency physicians (EP) frequently encounter. To address interruptions such as ECG interpretation, many EPs engage in task switching, pausing their primary task to address an interrupting task. The impact of task switching on clinical errors in interpreting screening ECGs for STEMI remains unknown. METHODS Resident and attending EPs were invited to participate in a crossover simulation trial. Physicians first completed a task-switching simulation in which they viewed patient presentations interrupted by clinical tasks, including screening ECGs requiring immediate interpretation before resuming the patient presentation. Participants then completed an uninterrupted simulation in which patient presentations and clinical tasks were completed sequentially without interruption. The primary outcome was accuracy of ECG interpretation for STEMI during task switching and uninterrupted simulations. RESULTS Thirty-five participants completed the study. We found no significant difference in accuracy of ECG interpretation for STEMI (task switching 0.89, uninterrupted 0.91, paired t-test p=0.21). Attending physician status (odds ratio [OR] [2.56], confidence interval [CI] [1.66-3.94], p<0.01) and inferior STEMI (OR [0.08], CI [0.04-0.14], p<0.01) were associated with increased and decreased odds of correct interpretation, respectively. Low self-reported confidence in interpretation was associated with decreased odds of correct interpretation in the task-switching simulation, but not in the uninterrupted simulation (interaction p=0.02). CONCLUSION In our simulation, task switching was not associated with overall accuracy of ECG interpretation for STEMI. However, odds of correct interpretation decreased with inferior STEMI ECGs and when participants self-reported low confidence when interrupted. Our study highlights opportunities to improve through focused ECG training, as well as self-identification of "high-risk" screening ECGs prone to error during interrupted clinical workflow.
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Affiliation(s)
- William E. Soares
- University of Massachusetts Medical School-Baystate, Department of Emergency Medicine, Springfield, Massachusetts
| | - Lori L. Price
- Clinical and Translational Science Institute, Tufts Medical Center and Institute for Clinical Research and Health Policy Studies, Tufts Medical Center Boston, Massachusetts
| | - Brendan Prast
- University of Massachusetts Medical School-Baystate, Academic Affairs, Springfield Massachusetts
| | - Elizabeth Tarbox
- University of Massachusetts Medical School-Baystate, Academic Affairs, Springfield Massachusetts
| | - Timothy J. Mader
- University of Massachusetts Medical School-Baystate, Department of Emergency Medicine, Springfield, Massachusetts
| | - Rebecca Blanchard
- University of Massachusetts Medical School-Baystate, Academic Affairs, Springfield Massachusetts
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Fore A, Islim F, Shever L. Data collected by the electronic health record is insufficient for estimating nursing costs: An observational study on acute care inpatient nursing units. Int J Nurs Stud 2018; 91:101-107. [PMID: 30677587 DOI: 10.1016/j.ijnurstu.2018.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/28/2018] [Accepted: 11/03/2018] [Indexed: 11/30/2022]
Abstract
Introduction As the electronic health record becomes more sophisticated, commensurate advances in cost accounting have risen as a top priority for hospital leaders. This study explored: 1) the average time to complete common nursing tasks documented in the electronic health record, 2) nursing-related tasks that remain undocumented, 3) the association between observation data and actual nursing documentation, and 4) considerations for model development and report design to be used for activity based cost accounting in nursing. Methods This was an observational study completed on acute care inpatient nursing units at a large academic medical center. During a five-week period, 63 nurses from 25 units were observed for over 250 h. Results Nearly 60% of the observed nursing activities did not fit into categories readily available in, and easily abstracted from, the electronic health record. The undocumented activities accounted for over half of the observation tasks and equated to nearly 130 h, in which over 40 h were spent on the activity of documentation/charting itself. Furthermore, nearly 36 h were spent on communication, followed by 13.5 h on monitoring/surveillance, two critical tasks in nursing which cannot be overlooked. Conclusions Using the electronic health record for cost accounting in nursing is a novel approach. In addition to the electronic health record, supplementary sources of data must be included to accurately capture nursing work and associated costs. Findings and lessons learned from this study will be used to guide future work and develop a model that determines the cost of nursing care and improved value in hospitalized patients.
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Affiliation(s)
- Amanda Fore
- Nursing Quality, Research, and Innovation, Michigan Medicine, University of Michigan, North Ingalls Building, Room 5A15, 300 N Ingalls, SPC 5446, Ann Arbor, MI 48109-5446, United States.
| | - Fadi Islim
- Nursing Informatics, Michigan Medicine, University of Michigan, United States
| | - Leah Shever
- Nursing Quality, Research, and Innovation, Michigan Medicine, University of Michigan, United States
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Schneider A, Wehler M, Weigl M. Provider interruptions and patient perceptions of care: an observational study in the emergency department. BMJ Qual Saf 2018; 28:296-304. [PMID: 30337495 DOI: 10.1136/bmjqs-2018-007811] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 08/15/2018] [Accepted: 09/07/2018] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Anna Schneider
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich
| | - Markus Wehler
- Department of Emergency Medicine and Department of Medicine IV, Klinikum Augsburg, Augsburg, Germany
| | - Matthias Weigl
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich
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Fong A, Ratwani RM. Understanding Emergency Medicine Physicians Multitasking Behaviors Around Interruptions. Acad Emerg Med 2018; 25:1164-1168. [PMID: 29888519 DOI: 10.1111/acem.13496] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/22/2018] [Accepted: 06/05/2018] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Allan Fong
- MedStar Institute for Innovation National Center for Human Factors in Healthcare Washington DC
| | - Raj M. Ratwani
- MedStar Institute for Innovation National Center for Human Factors in Healthcare Washington DC
- Georgetown University School of Medicine Washington DC
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Walter SR. Interruptions in Emergency Medicine: Things Are Not Always What They Seem. Acad Emerg Med 2018; 25:1178-1180. [PMID: 29924431 DOI: 10.1111/acem.13505] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Scott R. Walter
- Centre for Health Systems and Safety Research Australian Institute of Health Innovation Faculty of Medicine and Health Sciences, Macquarie University Sydney NSW Australia
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Westbrook JI, Raban MZ, Walter SR, Douglas H. Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study. BMJ Qual Saf 2018; 27:655-663. [PMID: 29317463 PMCID: PMC6204927 DOI: 10.1136/bmjqs-2017-007333] [Citation(s) in RCA: 145] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 12/20/2017] [Accepted: 12/22/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Interruptions and multitasking have been demonstrated in experimental studies to reduce individuals' task performance. These behaviours are frequently used by clinicians in high-workload, dynamic clinical environments, yet their effects have rarely been studied. OBJECTIVE To assess the relative contributions of interruptions and multitasking by emergency physicians to prescribing errors. METHODS 36 emergency physicians were shadowed over 120 hours. All tasks, interruptions and instances of multitasking were recorded. Physicians' working memory capacity (WMC) and preference for multitasking were assessed using the Operation Span Task (OSPAN) and Inventory of Polychronic Values. Following observation, physicians were asked about their sleep in the previous 24 hours. Prescribing errors were used as a measure of task performance. We performed multivariate analysis of prescribing error rates to determine associations with interruptions and multitasking, also considering physician seniority, age, psychometric measures, workload and sleep. RESULTS Physicians experienced 7.9 interruptions/hour. 28 clinicians were observed prescribing 239 medication orders which contained 208 prescribing errors. While prescribing, clinicians were interrupted 9.4 times/hour. Error rates increased significantly if physicians were interrupted (rate ratio (RR) 2.82; 95% CI 1.23 to 6.49) or multitasked (RR 1.86; 95% CI 1.35 to 2.56) while prescribing. Having below-average sleep showed a >15-fold increase in clinical error rate (RR 16.44; 95% CI 4.84 to 55.81). WMC was protective against errors; for every 10-point increase on the 75-point OSPAN, a 19% decrease in prescribing errors was observed. There was no effect of polychronicity, workload, physician gender or above-average sleep on error rates. CONCLUSION Interruptions, multitasking and poor sleep were associated with significantly increased rates of prescribing errors among emergency physicians. WMC mitigated the negative influence of these factors to an extent. These results confirm experimental findings in other fields and raise questions about the acceptability of the high rates of multitasking and interruption in clinical environments.
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Affiliation(s)
- Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW 2109, Australia
| | - Magdalena Z Raban
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW 2109, Australia
| | - Scott R Walter
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW 2109, Australia
| | - Heather Douglas
- School of Psychology and Exercise Science, Murdoch University, Singapore, Singapore
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Gloaguen A, Mauger T, Lefort H, Duchenne J, Martinez M, Le Conte P, Philippon AL, Truchot J, Freund Y. Actualités en médecine d’urgence. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Chan TM, Mercuri M, Van Dewark K, Sherbino J, Schwartz A, Norman G, Lineberry M. Managing Multiplicity: Conceptualizing Physician Cognition in Multipatient Environments. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:786-793. [PMID: 29210754 DOI: 10.1097/acm.0000000000002081] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE Emergency physicians (EPs) regularly manage multiple patients simultaneously, often making time-sensitive decisions around priorities for multiple patients. Few studies have explored physician cognition in multipatient scenarios. The authors sought to develop a conceptual framework to describe how EPs think in busy, multipatient environments. METHOD From July 2014 to May 2015, a qualitative study was conducted at McMaster University, using a think-aloud protocol to examine how 10 attending EPs and 10 junior residents made decisions in multipatient environments. Participants engaged in the think-aloud exercise for five different simulated multipatient scenarios. Transcripts from recorded interviews were analyzed inductively, with an iterative process involving two independent coders, and compared between attendings and residents. RESULTS The attending EPs and junior residents used similar processes to prioritize patients in these multipatient scenarios. The think-aloud processes demonstrated a similar process used by almost all participants. The cognitive task of patient prioritization consisted of three components: a brief overview of the entire cohort of patients to determine a general strategy; an individual chart review, whereby the participant created a functional patient story from information available in a file (i.e., vitals, brief clinical history); and creation of a relative priority list. Compared with residents, the attendings were better able to construct deeper and more complex patient stories. CONCLUSIONS The authors propose a conceptual framework for how EPs prioritize care for multiple patients in complex environments. This study may be useful to teachers who train physicians to function more efficiently in busy clinical environments.
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Affiliation(s)
- Teresa M Chan
- T.M. Chan is assistant professor, Division of Emergency Medicine, Department of Medicine, Michael G. DeGroote School of Medicine, program director, Clinician Educator Area of Focused Competence program, and adjunct scientist, McMaster Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada; ORCID: 0000-0001-6104-462X. M. Mercuri is assistant professor, Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. K. Van Dewark is clinical instructor, Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada. J. Sherbino is associate professor, Division of Emergency Medicine, Department of Medicine, Michael G. DeGroote School of Medicine, and assistant dean of education research, and director, McMaster Education Research, Innovation, and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada. A. Schwartz is Michael Reese Endowed Professor of Medical Education, associate head, Department of Medical Education, and research professor, Department of Pediatrics, College of Medicine, University of Illinois at Chicago; ORCID: 0000-0003-3809-6637. G. Norman is professor emeritus, Department of Clinical Epidemiology Biostatistics, and founding member, Program for Education Research and Development, and scientist, McMaster Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada. M. Lineberry is director, Simulation Research, Assessment, and Outcomes, Zamierowski Institute for Experiential Learning, and assistant professor, Department of Health Policy and Management, University of Kansas Medical Center, Kansas City, Kansas
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The Stay S.A.F.E. Strategy for Managing Interruptions Reduces Distraction Time in the Simulated Clinical Setting. Crit Care Nurs Q 2018; 41:215-223. [DOI: 10.1097/cnq.0000000000000201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Weigl M, Beck J, Wehler M, Schneider A. Workflow interruptions and stress atwork: a mixed-methods study among physicians and nurses of a multidisciplinary emergency department. BMJ Open 2017; 7:e019074. [PMID: 29275350 PMCID: PMC5770922 DOI: 10.1136/bmjopen-2017-019074] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Matthias Weigl
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Joana Beck
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Markus Wehler
- Department of Emergency Medicine and Medicine IV, Klinikum Augsburg, Augsburg, Germany
| | - Anna Schneider
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
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Ratwani RM, Fong A, Puthumana JS, Hettinger AZ. Emergency Physician Use of Cognitive Strategies to Manage Interruptions. Ann Emerg Med 2017; 70:683-687. [PMID: 28601266 DOI: 10.1016/j.annemergmed.2017.04.036] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 04/15/2017] [Accepted: 04/20/2017] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE The purpose of this study is to examine whether emergency physicians use strategies to manage interruptions during clinical work. Interruption management strategies include immediately engaging the interruption by discontinuing the current task and starting the interruption, continuing the current task while engaging the interruption, rejecting the interruption, or delaying the interruption. METHODS An observational time and motion study was conducted in 3 different urban, academic emergency departments with 18 attending emergency physicians. Each physician was observed for 2 hours, and the number of interruptions, source of interruptions, type of task being interrupted, and use of interruption management strategies were documented. RESULTS Participants were interrupted on average of 12.5 times per hour. The majority of interruptions were in person from other staff, including nurses, residents, and other attending physicians. When participants were interrupted, they were often working on their computer. Participants almost always immediately engaged the interruption task (75.4% of the time), followed by multitasking, in which the primary task was continued while the interrupting task was performed (22.2%). Physicians rejected or delayed interruptions less than 2% of the time. CONCLUSION Our results suggest there is an opportunity to introduce emergency physicians to the use of interruption management strategies as a method of handling the frequent interruptions they are exposed to. Use of these strategies when high-risk primary tasks are performed may reduce the disruptiveness of some interruptions and improve patient safety.
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Affiliation(s)
- Raj M Ratwani
- National Center for Human Factors in Healthcare, MedStar Health, Washington, DC; Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC.
| | - Allan Fong
- National Center for Human Factors in Healthcare, MedStar Health, Washington, DC
| | - Josh S Puthumana
- National Center for Human Factors in Healthcare, MedStar Health, Washington, DC
| | - Aaron Z Hettinger
- National Center for Human Factors in Healthcare, MedStar Health, Washington, DC; Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC
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McCurdie T, Sanderson P, Aitken LM. Traditions of research into interruptions in healthcare: A conceptual review. Int J Nurs Stud 2016; 66:23-36. [PMID: 27951432 DOI: 10.1016/j.ijnurstu.2016.11.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 11/06/2016] [Accepted: 11/06/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Researchers from diverse theoretical backgrounds have studied workplace interruptions in healthcare, leading to a complex and conflicting body of literature. Understanding pre-existing viewpoints may advance the field more effectively than attempts to remove bias from investigations. OBJECTIVE To identify research traditions that have motivated and guided interruptions research, and to note research questions posed, gaps in approach, and possible avenues for future research. METHODS A critical review was conducted of research on interruptions in healthcare. Two researchers identified core research communities based on the community's motivations, philosophical outlook, and methods. Among the characteristics used to categorise papers into research communities were the predominant motivation for studying interruptions, the research questions posed, and key contributions to the body of knowledge on interruptions in healthcare. In cases where a paper approached an equal number of characteristics from two traditions, it was placed in a blended research community. RESULTS A total of 141 papers were identified and categorised; all papers identified were published from 1994 onwards. Four principal research communities emerged: epidemiology, quality improvement, cognitive systems engineering (CSE), and applied cognitive psychology. Blends and areas of mutual influence between the research communities were identified that combine the benefits of individual traditions, but there was a notable lack of blends incorporating quality improvement initiatives. The question most commonly posed by researchers across multiple communities was: what is the impact of interruptions? Impact was measured as a function of task time or risk in the epidemiology tradition, situation awareness in the CSE tradition, or resumption lag (time to resume an interrupted task) in the applied cognitive psychology tradition. No single question about interruptions in healthcare was shared by all four of the core communities. CONCLUSIONS Much research on workplace interruptions in healthcare can be described in terms of fundamental values of four distinct research traditions and the communities that bring the values and methods: of those research traditions to their investigations. Blends between communities indicate that mutual influence has occurred as interruptions research has progressed. It is clear from this review that there is no single or privileged perspective to study interruptions. Instead, these findings suggest that researchers investigating interruptions in healthcare would benefit from being more aware of different perspectives from their own, especially when they consider workplace interventions to reduce interruptions.
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Affiliation(s)
- Tara McCurdie
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane 4072, Australia.
| | - Penelope Sanderson
- Schools of Information Technology and Electrical Engineering, of Psychology, and of Medicine, The University of Queensland, Brisbane, Australia
| | - Leanne M Aitken
- School of Nursing & Midwifery, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia; School of Health Sciences, City University London, London, United Kingdom
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