Emergency physicians’ behaviors and workload in the presence of an electronic whiteboard

The Impact of Patient Race, Patient Socioeconomic Status, and Cognitive Load of Physician Residents and Fellows on Chronic Pain Care Decisions

Social stereotypes are more likely to influence decision-making under conditions of high cognitive load (ie, mental workload), such as in medical settings. We examined how patient race, patient socioeconomic status (SES), physician cognitive load, and physician implicit beliefs about race and SES differences in pain tolerance impacted physicians' pain treatment decisions. Physician residents and fellows (N = 120) made treatment decisions for 12 computer-simulated patients with back pain that varied by race (Black/White) and SES (low/high). Half of the physicians were randomized to be interrupted during the decision task to make hypertension medication conversion calculations (high cognitive load group), while the other half completed the task without interruptions (low cognitive load group). Both groups were given equal time to make pain care decisions (2.5 minutes/patient). Results of multilevel ordinal logistic regression analyses indicated that physicians prescribed weaker analgesics to patients with high vs. low SES (odds ratio = .68, 95% confidence interval [.48, .97], P = .03). There was also a patient SES-by-cognitive load interaction (odds ratio = .56, 95% confidence interval [.31, 1.01], P = .05) that is theoretically and potentially practically meaningful but was not statistically significant at P < .05. These findings shed light on physician cognitive load as a clinically-relevant factor in the context of pain care quality and equity. PERSPECTIVE: These findings highlight the clinical relevance of physician cognitive load (eg, mental workload) when providing pain care for diverse patients. This line of work can support the development of interventions to manage physician cognitive load and its impact on pain care, which may ultimately help reduce pain disparities.

Workload In Neonatology (WORKLINE): Validation and feasibility of a system for measuring clinician workload integrated into the electronic health record

OBJECTIVE

The purpose of the study was to validate WORKLINE, a NICU specific clinician workload model and to evaluate the feasibility of integrating WORKLINE into our EHR.

STUDY DESIGN

This was a prospective, observational study of the workload of 42 APPs and physicians in a large academic medical center NICU over a 6-month period. We used regression models with robust clustered standard errors to test associations of WORKLINE values with NASA Task Load Index (NASA-TLX) scores.

RESULTS

We found significant correlations between WORKLINE and NASA-TLX scores. APP caseload was not significantly associated with WORKLINE scores. We successfully integrated the WORKLINE model into our EHR to automatically generate workload scores.

CONCLUSION

WORKLINE provides an objective method to quantify the workload of clinicians in the NICU, and for APPs, performed better than caseload numbers to reflect workload. Integrating the WORKLINE model into the EHR was feasible and enabled automated workload scores.

Requirements and challenges of hospital dashboards: a systematic literature review

Background

Today, the use of data in administrative and clinical processes is quite challenging due to the large volume of data, data collection from various sources, and lack of data structure. As a data management tool, dashboards play an important role in timely visual display of critical information on key performances.

Objectives

This systematic review aimed to identify functional and non-functional requirements, as well as challenges of using dashboards in hospitals.

Methods

In this systematic review, four databases, including the Web of Science, PubMed, EMBASE, and Scopus, were searched to find relevant articles from 2000 until May 30, 2020. The final search was conducted on May 30, 2020. Data collection was performed using a data extraction form and reviewing the content of relevant studies on the potentials and challenges of dashboard implementation.

Results

Fifty-four out of 1254 retrieved articles were selected for this study based on the inclusion and exclusion criteria. The functional requirements for dashboards included reporting, reminders, customization, tracking, alert creation, and assessment of performance indicators. On the other hand, the non-functional requirements included the dashboard speed, security, ease of use, installation on different devices (e.g., PCs and laptops), integration with other systems, web-based design, inclusion of a data warehouse, being up-to-data, and use of data visualization elements based on the user’s needs. Moreover, the identified challenges were categorized into four groups: data sources, dashboard content, dashboard design, implementation, and integration in other systems at the hospital level.

Conclusion

Dashboards, by providing information in an appropriate manner, can lead to the proper use of information by users. In order for a dashboard to be effective in clinical and managerial processes, particular attention must be paid to its capabilities, and the challenges of its implementation need to be addressed.

Learning to See: Using Mixed OR Methods to Model Radiology Staff Workload and Support Decision Making in CT

Demand for Computer Tomography (CT) is growing year on year and the population of Ireland is increasingly aging and ailing. Anecdotally, radiology staff reported increasing levels of workload associated with the patient profile. In this paper, we propose a framework combining discrete event simulation (DES) modeling and soft systems methodologies (SSM) for use in healthcare which captures the staff experience and metrics to evidence workload. The framework was applied in a single-scanner CT department, which completes circa 6000 examinations per year. The scanner case load consists of unscheduled work [inpatient (IP) and emergency department (ED)] and scheduled work [outpatient (OP) and general practitioner (GP)]. The three stage framework is supported by qualitative and quantitative methods and uses DES as a decision support tool. Firstly, workflow mapping and system dynamics are used to conceptualize the problem situation and instigate a preliminary data analysis. Secondly, SSM tools are used to identify components for a DES model and service improvement scenarios. Lastly, the DES model results are used to inform decision-making and identify a satisficing solution. Data from the DES model provided evidence of the differing workload (captured in staff time) for the IP and OP cohorts. For non-contrast examinations, inpatient workload is 2.5 times greater than outpatient. Average IP process delays of 11.9 min were demonstrated compared to less than 1 min for OP. The findings recommend that OP and IP diagnostic imaging be provided separately, for efficiency, workload management and infection control reasons.

An Observational Study of Physicians' Workflow Interruptions in Outpatient Departments in China

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.

The presentations/physician ratio predicts door-to-physician time but not global length of stay in the emergency department: an Italian multicenter study during the SARS-CoV-2 pandemic

To investigate the effects of the dramatic reduction in presentations to Italian Emergency Departments (EDs) on the main indicators of ED performance during the SARS-CoV-2 pandemic. From February to June 2020 we retrospectively measured the number of daily presentations normalized for the number of emergency physicians on duty (presentations/physician ratio), door-to-physician and door-to-final disposition (length-of-stay) times of seven EDs in the central area of Tuscany. Using the multivariate regression analysis we investigated the relationship between the aforesaid variables and patient-level (triage codes, age, admissions) or hospital-level factors (number of physician on duty, working surface area, academic vs. community hospital). We analyzed data from 105,271 patients. Over ten consecutive 14-day periods, the number of presentations dropped from 18,239 to 6132 (- 67%) and the proportion of patients visited in less than 60 min rose from 56 to 86%. The proportion of patients with a length-of-stay under 4 h decreased from 59 to 52%. The presentations/physician ratio was inversely related to the proportion of patients with a door-to-physician time under 60 min (slope - 2.91, 95% CI - 4.23 to - 1.59, R² = 0.39). The proportion of patients with high-priority codes but not the presentations/physician ratio, was inversely related to the proportion of patients with a length-of-stay under 4 h (slope - 0.40, 95% CI - 0.24 to - 0.27, R² = 0.36). The variability of door-to-physician time and global length-of-stay are predicted by different factors. For appropriate benchmarking among EDs, the use of performance indicators should consider specific, hospital-level and patient-level factors.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Study objective

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

Methods

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

Results

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

Conclusion

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

A Time and Motion Analysis of Nursing Workload and Electronic Health Record Use in the Emergency Department

INTRODUCTION

The use of an electronic health record may create unanticipated consequences for emergency care delivery. We sought to describe emergency department nursing task distribution and the use of the electronic health record.

METHODS

This was a prospective observational study of nurses in the emergency department using a time-and-motion methodology. Three trained research assistants conducted 1:1 observations between March and September 2019. Nurse tasks were classified into 6 established categories: electronic health record, direct/indirect patient care, communication, personal time, and other. Nurses' perceived workload was assessed using the National Aeronautics and Space Administration (NASA) Task Load Index.

RESULTS

Twenty-three observations were conducted over 46 hours. Overall, nurses spent 27% of their time on electronic health record tasks, 25% on direct patient care, 17% on personal time, 15% on indirect patient care, and 6% on communication. During morning (7 am-12 pm) and afternoon shifts (12 pm-3 pm), the use of the health record was the most commonly performed task, whereas indirect patient care was the task most performed during evening shifts (3 pm-12 pm). Using the National Aeronautics and Space Administration (NASA) Task Load Index, nurses reported an increase in mental demand and effort during afternoon shifts compared with morning shifts.

DISCUSSION

We observed that emergency nurses spent more time using the electronic health record as compared to other tasks. Increased usability of the electronic health record, particularly during high occupancy periods, may be a target for improvement.

Emergency Department Quality Dashboard; a Systematic Review of Performance Indicators, Functionalities, and Challenges

Introduction:

Effective information management in the emergency department (ED) can improve the control and management of ED processes. Dashboards, known as data management tools, efficiently provide information and contribute greatly to control and management of ED. This study aimed to identify performance indicators quality dashboard functionalities, and analyze the challenges associated with dashboard implementation in the ED.

Methods:

This systematic review began with a search in four databases (Web of Science, PubMed, Embase, and Scopus) from 2000 to May 30, 2020, when the final search for papers was conducted. The data were collected using a data extraction form and the contents of the extracted papers were analyzed through ED performance indicators, dashboard functionalities, and implementation challenges.

Results:

Performance indicators reported in the reviewed papers were classified as the quality of care, patient flow, timeliness, costs, and resources. The main dashboard functionalities noted in the papers included reporting, customization, alert creation, resource management, and real-time information display. The dashboard implementation challenges included data sources, data quality, integration with other systems, adaptability of dashboard functionalities to user needs, and selection of appropriate performance indicators.

Conclusions:

Quality dashboards facilitate processes, communication, and situation awareness in the ED; hence, they can improve care provision in this department. To enhance the effectiveness and efficiency of ED dashboards, officials should set performance indicators and consider the conformity of dashboard functionalities with user needs. They should also integrate dashboards with other relevant systems at the departmental and hospital levels.

Never Enough Time: Mixed Methods Study Identifies Drivers of Temporal Demand That Contribute to Burnout Among Physicians Who Care for Pediatric Hematology-Oncology Patients

PURPOSE

Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment because of chronic occupational stress. Approximately one third of pediatric hematology-oncology physicians experience burnout. The goal of this mixed methods study was to determine the prevalence and drivers of burnout among physicians caring for pediatric hematology-oncology patients at our institution.

MATERIALS AND METHODS

This mixed methods, cross-sectional study was conducted at a large academic cancer center. Validated survey instruments were used to measure burnout, job demands, experience with patient safety events, and workplace culture. Quantitative data informed development of a semistructured interview guide, and physicians were randomly selected to participate in individual interviews. Interviews were transcribed and analyzed via content analysis based on a priori codes.

RESULTS

The survey was distributed to 132 physicians, and 53 complete responses were received (response rate 40%). Of the 53 respondents, 15 (28%) met criteria for burnout. Experiencing burnout was associated with increased temporal demand. Twenty-six interviews were conducted. Qualitative themes revealed that frequent meetings, insufficient support staff, and workflow interruptions were key drivers of temporal demand and that temporal demand contributed to burnout through emotional exhaustion and reduced personal accomplishment.

CONCLUSION

Nearly one-third of participating physicians met criteria for burnout, and burnout was associated with increased temporal demand. Qualitative interviews identified specific drivers of temporal demand and burnout, which can be targeted for intervention. This methodology can be easily adapted for broad use and may represent an effective strategy for identifying and mitigating institution-specific drivers of burnout.

Electronic whiteboard implementation as a quality management tool optimizes IVF laboratory standardization and improves clinical outcomes

PURPOSE

To test whether an electronic whiteboard in the IVF laboratory increases the likelihood that critical evaluation procedures are performed within optimum pre-set time ranges.

METHODS

A retrospective cohort study of oocyte retrievals in our IVF clinic between 06/01/2012 and 05/31/2018 was included. The electronic whiteboard was introduced on 04/06/2014. Prior to implementation, embryologists strived to adhere to the set evaluation times without a formal guide. The primary outcomes were the proportion of embryologist evaluations performed in optimum time ranges and the proportion of usable embryos per patient.

RESULTS

A total of 4645 retrievals met inclusion criteria. Implementation of the whiteboard was associated with (1) an increase in the proportion of fertilization checks performed within the optimum time range for ICSI cycles (+ 5.1%, RR = 1.06, CI = 1.02-1.10); (2) an increase in the proportion of day 3 evaluations performed within the optimum time range, whether assisted hatching was performed (+ 23.6%, RR = 1.48, CI = 1.36-1.60) or not (+ 13.8%, RR = 1.23, CI = 1.12-1.35); and (3) an increase in the proportion of day 5 evaluations within the optimum time range (+ 15.5%, RR = 1.23, CI = 1.12-1.35). Additionally, the mean number of usable embryos per patient increased from 2.8 to 4.5 after the whiteboard was implemented (RR = 1.25, CI = 1.19-1.31).

CONCLUSION

The use of an electronic whiteboard that posts optimum times for performing critical procedures significantly increases the proportion of evaluations that occur within these ranges. Such improved standardization led to positive downstream effects on the number of usable embryos per patient. We suggest that electronic whiteboard implementation driven by real-time data collection should be considered in all IVF laboratories.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

[Mental Workload Assessment of Health Care Staff by NASA-TLX]

The National Aeronautics Space Administration Task Load Index (NASA-TLX) is the most frequently used mental workload assessment method. This article reviews 26 papers which report mental workload evaluation in health care staff, categorizing them into laparoscopic surgery, anesthesia, ICU, electronic record, patient controlled analgesia, emergency, display and others. Although indices other than NASA-TLX were also used in these papers, this review describes the results of NASA-TLX only.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Relationship between number of health problems addressed during a primary care patient visit and clinician workload

INTRODUCTION

Primary care is complex due to multiple health problems being addressed in each patient visit. Little is known about the effect of the number of problems per encounter (NPPE) on the resulting clinician workload (CWL), as measured using the National Aeronautics and Space Administration Task Load Index (NASA-TLX).

METHODS

We evaluated the relationship between NPPE and CWL across 608 adult patient visits, conducted by 31 clinicians, using hierarchical linear regression. Clinicians were interviewed about outlier visits to identify reasons for higher or lower than expected CWL.

RESULTS

Mean NPPE was 3.30 ± 2.0 (sd) and CWL was 47.6 ± 18.4 from a maximum of 100. Mental demand, time demand and effort accounted for 71.5% of CWL. After adjustment for confounders, each additional problem increased CWL by 3.9 points (P < 0.001). Patient, problem, environmental and patient-physician relationship factors were qualitatively identified from interviews as moderators of this effect.

CONCLUSION

CWL is positively related to NPPE. Several modifiable factors may enhance or mitigate this effect. Our findings have implications for using a Human Factors (HF) approach to managing CWL.

[Time-allocation study of nurse and physician activities in the emergency department]

Hintergrund

Systematische und vergleichende Analysen der Tätigkeiten des ärztlichen und pflegerischen Personals in der Notaufnahme fehlen für den deutschsprachigen Bereich.

Ziel der Arbeit

Analyse der Aktivitäten des pflegerischen und ärztlichen Personals einer Notaufnahme sowie der Anteile direkten Patientenkontakts und stündlicher Tätigkeitswechsel.

Material und Methoden

Tätigkeitsanalysen auf Basis teilnehmender Beobachtungen (je 90 min) bei Pflegekräften und Ärzt*innen einer interdisziplinären Notaufnahme eines süddeutschen Krankenhauses der Maximalversorgung. Beobachtete Tätigkeiten wurden anhand eines Klassifikationssystems mitsamt Zeitdauern kodiert. Insgesamt wurden 160 Einzelbeobachtungen (mit einer Gesamtzeit von ca. 240 h) durchgeführt; 99 bei Pflegekräften sowie 61 bei Ärzt*innen.

Ergebnisse

Notaufnahmeärzt*innen arbeiten 30 % ihrer Zeit in direktem Patientenkontakt, Pflegekräfte hingegen 44 %. Für die Einzeltätigkeiten entfielen die größten Zeitanteile ärztlicher Tätigkeit auf Dokumentation und Schriftarbeit (29,3 %), interne Kommunikation mit Personal (16,9 %) sowie mit Patient*innen (13,6 %). Pflegekräfte verwenden die meiste Zeit auf therapeutische und Behandlungsaktivitäten (27,6 %) sowie interne Kommunikation (17,9 %). Diese Tätigkeiten waren stark fragmentiert: Im Durchschnitt erfassten wir 41,3 Einzeltätigkeiten pro Stunde mit einer durchschnittlichen Dauer von 1,5 min. Pflegekräfte hatten signifikant kürzere Tätigkeitsdauern als Ärzt*innen (F[df = 1] = 4,5; p = 0,04). Tätigkeitsspezifische Analysen ergaben weitere Professionsunterschiede.

Diskussion

Unsere Ergebnisse liefern erstmalig fundierte Einsichten in die Verteilung und Dauer von ärztlichen sowie pflegerischen Tätigkeiten in der akutmedizinischen Versorgung in der Notaufnahme. Zukünftige Arbeiten sollten sich insbesondere einhergehenden Auswirkungen auf die Leistungsfähigkeit und Beanspruchung des Personals wie auch der Sicherheit und Qualität der Versorgung widmen.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00063-020-00657-4) enthält die Tabelle S1. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

Assessment of perceived workload in academic health center community pharmacies before and after implementation of a central call center

PURPOSE

Results of a study to determine whether reducing pharmacy phone call workload through implementation of a pharmacy services call center (PSCC) led to decreased employee workload, improved efficiency, and increased pharmacist availability for patient care are reported.

METHODS

A pre-post study was conducted using the NASA Task Load Index (NASA-TLX) instrument. Pharmacists, pharmacy technicians at 7 academic health center community pharmacies, and PSCC staff provided NASA-TLX data over 5 days during 3 data collection periods before and after PSCC implementation. Perceived workload was measured as an overall workload score (OWS) and mean scores for 6 NASA-TLX workload dimensions (mental demand, physical demand, temporal demand, performance, effort, and frustration).

RESULTS

Relative to pre-PSCC values, mean postimplementation OWS scores significantly decreased in all 7 pharmacies (from 33.3 to 29.1 overall, p < 0.001) but especially in small pharmacies (from 31.7 to 27.6, p < 0.001). Scores for the physical demand and frustration dimensions were low in both the PSCC and in the 7 pharmacies, while scores for the performance dimension remained high (range, 6.8-8.3). In general, scores for all other measured NASA-TLX dimensions decreased after PSCC implementation, more so at smaller pharmacies. The PSCC staff mean OWS score increased over time (from 26.8 to 28.6, p < 0.0001) but remained near the overall pharmacy average of 29.1.

CONCLUSION

Use of the NASA TLX allowed for a direct subjective measurement of workload as perceived by pharmacy and PSCC employees before and after PSCC implementation. Long-term effects of the PSCC on workload should be assessed.

Understanding better how emergency doctors work. Analysis of distribution of time and activities of emergency doctors: a systematic review and critical appraisal of time and motion studies

BACKGROUND

Optimising the efficiency and productivity of senior doctors is critical to ED function and delivery of safe patient care. Time and motion studies (TMS) can allow quantification of how these doctors spend their working time, identify inefficiencies in the current work processes and provide insights into improving working conditions, and enhancing productivity. Three questions were addressed: (1) How do senior emergency doctors spend their time in the ED? (2) How much of their time is spent on multitasking? (3) What is the number of tasks completed per hour?

METHODS

The literature was systematically searched for TMS of senior emergency doctors. We searched for articles published in peer-reviewed journals in English language from 1998 to 2018 in the following databases: MEDLINE, EMBASE, Scopus, Web of Science and Cochrane. Studies were assessed for methodological quality using evidence-based quality criteria relevant for TMS including duration of observation, observer bias, Hawthorne effect and whether the task classification acknowledged any previous existing schemes. A narrative synthesis approach was followed.

RESULTS

Fourteen TMS were included. The studies were liable to several biases including observer and Hawthorne bias. Overall, the time spent on direct face-to-face contact with the patient accounted for at least around 25%-40% of the senior doctors' time. The remaining time was mostly spent on indirect clinical care such as communication (8%-44%), documentation (10%-28%) and administrative tasks (2%-20%). The proportion of time spent on multitasking ranged from 10% to 23%. When reported, the number of tasks performed per hour was generally high.

CONCLUSION

The review revealed that senior doctors spent a large percentage of their time on direct face-to-face contact with patients. The review findings provided a grounded understanding of how senior doctors spent their time in the ED and could be useful in implementing improvements to the emergency care system.

Communication Strategies for Better Care of Older Individuals in the Emergency Department

The need for teamwork and communication among emergency department staff is central to excellent health care and of particular importance for the complex older adult population. Communication can decrease error, enhance safety, and improve throughput. Communication strategies both among multiple health care professionals, and between professionals and family and/or patients can improve care for older adults in the unique emergency department environment.

The Impact of Telemedicine on Teamwork and Workload in Pediatric Resuscitation: A Simulation-Based, Randomized Controlled Study

BACKGROUND

Telemedicine provides access to specialty care to critically ill patients from a geographic distance. The effects of using telemedicine on (1) teamwork and communication (TC), (2) task workload during resuscitation, and (3) the processes of critical care have not been well described.

OBJECTIVES

To evaluate the impact of telemedicine on (1) TC, (2) task workload during a resuscitation, and (3) the processes of critical care during a simulated pediatric resuscitation.

METHODS

Prospective single-center randomized trial. Teams of two physicians (senior and junior resident) and two standardized confederate nurses were randomized to either telemedicine (telepresent senior physician team leader) or usual care (both physicians in the room) during a simulated infant resuscitation. Simulations were video recorded and assessed for teamwork, workload, and processes of care using the Simulated Team Assessment Tool (STAT), the NASA Task Load Index (NASA-TLX) tool, and time between onset of ventricular fibrillation and defibrillation, respectively.

RESULTS

Twenty teams participated. There was no difference in teamwork between the groups (mean STAT score 72% vs. 69%; p = 0.383); however, there was a significantly greater workload in the telemedicine group (mean TLX score 56% vs. 48%, p = 0.020). Using linear regression, no difference was found in time-to-defibrillation between groups (p = 0.671), but higher teamwork scores predicted faster time to defibrillation (p = 0.020).

CONCLUSIONS

In this simulation-based study, a telepresent team leader was associated with increased team workload compared to usual care. However, no differences were noted in teamwork and processes of care metrics.

An Electronic Dashboard to Monitor Patient Flow at the Johns Hopkins Hospital: Communication of Key Performance Indicators Using the Donabedian Model

Efforts to monitoring and managing hospital capacity depend on the ability to extract relevant time-stamped data from electronic medical records and other information technologies. However, the various characterizations of patient flow, cohort decisions, sub-processes, and the diverse stakeholders requiring data visibility create further overlying complexity. We use the Donabedian model to prioritize patient flow metrics and build an electronic dashboard for enabling communication. Ten metrics were identified as key indicators including outcome (length of stay, 30-day readmission, operating room exit delays, capacity-related diversions), process (timely inpatient unit discharge, emergency department disposition), and structural metrics (occupancy, discharge volume, boarding, bed assignation duration). Dashboard users provided real-life examples of how the tool is assisting capacity improvement efforts, and user traffic data revealed an uptrend in dashboard utilization from May to October 2017 (26 to 148 views per month, respectively). Our main contributions are twofold. The former being the results and methods for selecting key performance indicators for a unit, department, and across the entire hospital (i.e., separating signal from noise). The latter being an electronic dashboard deployed and used at The Johns Hopkins Hospital to visualize these ten metrics and communicate systematically to hospital stakeholders. Integration of diverse information technology may create further opportunities for improved hospital capacity.

Examining barriers to healthcare providers' adoption of a hospital-wide electronic patient journey board

BACKGROUND

The dynamic environment that characterizes patient care in hospitals requires extensive communication between staff. Electronic status board applications are used to improve the flow of communication in hospitals. To date there has been limited work exploring the adoption of these applications in general acute ward settings.

AIM

This study aimed to identify barriers to the adoption of an electronic patient journey board (EPJB)¹ application in acute wards of a hospital.

METHOD

Data were collected at a large public teaching hospital in Sydney, Australia. The EPJB was implemented across all hospital wards with the aim of improving multidisciplinary communication in wards. Observations (29.5 h) and contextual interviews (n = 33) with hospital staff were conducted in two acute wards of the hospital.

RESULTS

Two manual whiteboards were used on wards, in addition to the EPJB, to compensate for information not being available or accessible on the EPJB. Despite the stated purpose of the EPJB, the tool did not appear to support team communication on wards. Barriers to adoption and optimal use of the EPJB included inappropriate location and configuration of the system, limitations in information timeliness, quality and lack of customisation (for different user groups), inconsistent information updates and the absence of a shared understanding of the purpose of the EPJB among the various user groups.

CONCLUSION

Multiple socio-technical barriers influenced uptake and optimal use of the EPJB by healthcare providers. Engaging users early in the design and implementation of electronic status board applications is required to ensure effective use of these complex interventions on general wards.

Modelling attending physician productivity in the emergency department: a multicentre study

Objectives

Emergency physician productivity, often defined as new patients evaluated per hour, is essential to planning clinical operations. Prior research in this area considered this a static quantity; however, our group’s study of resident physicians demonstrated significant decreases in hourly productivity throughout shifts. We now examine attending physicians’ productivity to determine if it is also dynamic.

Methods

This is a retrospective cohort study, conducted from 2014 to 2016 across three community hospitals in the north-eastern USA, with different schedules and coverage. Timestamps of all patient encounters were automatically logged by the sites’ electronic health record. Generalised estimating equations were constructed to predict productivity in terms of new patients per shift hour.

Results

207 169 patients were seen by 64 physicians over 2 years, comprising 9822 physician shifts. Physicians saw an average of 15.0 (SD 4.7), 20.9 (SD 6.4) and 13.2 (SD 3.8) patients per shift at the three sites, with 2.97 (SD 0.22), 2.95 (SD 0.24) and 2.17 (SD 0.09) in the first hour. Across all sites, physicians saw significantly fewer new patients after the first hour, with more gradual decreases subsequently. Additional patient arrivals were associated with greater productivity; however, this attenuates substantially late in the shift. The presence of other physicians was also associated with slightly decreased productivity.

Conclusions

Physician productivity over a single shift follows a predictable pattern that decreases significantly on an hourly basis, even if there are new patients to be seen. Estimating productivity as a simple average substantially underestimates physicians’ capacity early in a shift and overestimates it later. This pattern of productivity should be factored into hospitals’ staffing plans, with shifts aligned to start with the greatest volumes of patient arrivals.

Evaluation of Computerized Free Text Sign-Out Notes: Baseline Understanding and Recommendations

BACKGROUND: Standardization of sign-out, the transfer of patient information and responsibility between inpatient providers at shift change, is a Joint Commission National Patient Safety Goal intended to improve communication and reduce risk of error. Computerized systems with free text data entry and limited structure allow clinicians to generate sign-out notes in a variety of ways. OBJECTIVES: The literature lacks a systematic exploration of the range of content generated by users of computerized sign-out systems. The goal of this study was to determine if and how clinicians record standardized sign-out information using a system with free text data entry and limited structure. METHODS: Using qualitative methods, we reviewed free text sign-out notes for 730 patient cases across 39 hospital units at an academic medical center. RESULTS: Two categories of information expression emerged from analysis: patient treatment-comprised of patient summaries, awareness items, and action items-and care team coordination-consisting of discharge information, contact information, and social concerns. A third category describing the format of sign-out note content, presentation of information, also emerged. Location and structure of information varied, but sign-out note content for some hospital units exhibited specific characteristics and was relatively standardized. CONCLUSIONS: Findings provide a baseline understanding of computerized free text sign-out note content. Sign-out notes contained a synthesis of data from disparate sources. We recommend formalizing existing unit-specific content standardization and system use patterns to reduce sign-out note variability and improve communication.

Can teamwork and situational awareness (SA) in ED resuscitations be improved with a technological cognitive aid? Design and a pilot study of a team situation display

Effective teamwork in ED resuscitations, including information sharing and situational awareness, could be degraded. Technological cognitive aids can facilitate effective teamwork.

OBJECTIVE

This study focused on the design of an ED situation display and pilot test its influence on teamwork and situational awareness during simulated resuscitation scenarios.

MATERIAL AND METHODS

The display design consisted of a central area showing the critical dynamic parameters of the interventions with an events time-line below it. Static information was placed at the sides of the display. We pilot tested whether the situation display could lead to higher scores on the Clinical Teamwork Scale (CTS), improved scores on a context-specific Situational Awareness Global Assessment Technique (SAGAT) tool, and team communication patterns that reflect teamwork and situational awareness.

RESULTS

Resuscitation teamwork, as measured by the CTS, was overall better with the presence of the situation display as compared with no situation display. Team members discussed interventions more with the situation display compared with not having the situation display. Situational awareness was better with the situation display only in the trauma scenario.

DISCUSSION

The situation display could be more effective for certain ED team members and in certain cases.

CONCLUSIONS

Overall, this pilot study implies that a situation display could facilitate better teamwork and team communication in the resuscitation event.

Dashboard visualizations: Supporting real-time throughput decision-making

Providing timely and effective care in the emergency department (ED) requires the management of individual patients as well as the flow and demands of the entire department. Strategic changes to work processes, such as adding a flow coordination nurse or a physician in triage, have demonstrated improvements in throughput times. However, such global strategic changes do not address the real-time, often opportunistic workflow decisions of individual clinicians in the ED. We believe that real-time representation of the status of the entire emergency department and each patient within it through information visualizations will better support clinical decision-making in-the-moment and provide for rapid intervention to improve ED flow. This notion is based on previous work where we found that clinicians' workflow decisions were often based on an in-the-moment local perspective, rather than a global perspective. Here, we discuss the challenges of designing and implementing visualizations for ED through a discussion of the development of our prototype Throughput Dashboard and the potential it holds for supporting real-time decision-making.

Impact of simulated three-dimensional perception on precision of depth judgements, technical performance and perceived workload in laparoscopy

Background

This study compared precision of depth judgements, technical performance and workload using two‐dimensional (2D) and three‐dimensional (3D) laparoscopic displays across different viewing distances. It also compared the accuracy of 3D displays with natural viewing, along with the relationship between stereoacuity and 3D laparoscopic performance.

Methods

A counterbalanced within‐subjects design with random assignment to testing sequences was used. The system could display 2D or 3D images with the same set‐up. A Howard–Dolman apparatus assessed precision of depth judgements, and three laparoscopic tasks (peg transfer, navigation in space and suturing) assessed performance (time to completion). Participants completed tasks in all combinations of two viewing modes (2D, 3D) and two viewing distances (1 m, 3 m). Other measures administered included the National Aeronautics and Space Administration Task Load Index (perceived workload) and the Randot^® Stereotest (stereoacuity).

Results

Depth judgements were 6·2 times as precise at 1 m and 3·0 times as precise at 3 m using 3Dversus2D displays (P < 0·001). Participants performed all laparoscopic tasks faster in 3D at both 1 and 3 m (P < 0.001), with mean completion times up to 64 per cent shorter for 3Dversus2D displays. Workload was lower for 3D displays (up to 34 per cent) than for 2D displays at both viewing distances (P < 0·001). Greater viewing distance inhibited performance for two laparoscopic tasks, and increased perceived workload for all three (P < 0·001). Higher stereoacuity was associated with shorter completion times for the navigating in space task performed in 3D at 1 m (r = − 0·40, P = 0·001).

Conclusion

3D displays offer large improvements over 2D displays in precision of depth judgements, technical performance and perceived workload.

Many advantages for 3D

Work load and management in the delivery room: changing the direction of healthcare policy

Nurse staffing, increased workload and unstable nursing unit environments are linked to negative patient outcomes including falls and medication errors on medical/surgical units. Considering this evidence, the aim of our study was to overview midwives' workload and work setting. We created a questionnaire and performed an online survey. We obtained information about the type and level of hospital, workload, the use of standardised procedures, reporting of sentinel and 'near-miss' events. We reported a severe understaffing in midwives' work settings and important underuse of standard protocols according to the international guidelines, especially in the South of Italy. Based on our results, we strongly suggest a change of direction of healthcare policy, oriented to increase the number of employed midwives, in order to let them fulfil their duties according to the international guidelines (especially one-to-one care). On the other hand, we encourage the adoption of standardised protocols in each work setting.

Traditions of research into interruptions in healthcare: A conceptual review

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.

A Study of VITOM in Pediatric Surgery and Urology: Evaluation of Technology Acceptance and Usability by Operating Team and Surgeon Musculoskeletal Discomfort

INTRODUCTION

We studied operating team acceptability of Video Telescopic Monitor (VITOM^®) exoscope by exploring the ease of use of the device in two centers. We also assessed factors affecting surgeon musculoskeletal discomfort.

METHODS

We focused on how the operating team interacted with the VITOM system with surrogate measures of usefulness, image quality, ease of use, workload, and setup time. Multivariable linear regression was used to model the relationships between team role, experience, and setup time. Relationships between localized musculoskeletal discomfort and use of VITOM alone, and with loupes, were also analyzed.

RESULTS

Four surgeons, 7 surgical techs, 7 circulating nurses, and 13 surgical residents performed 70 pediatric surgical and urological operations. We found that subjective views of each team member were consistently positive with 69%-74% agreed or strongly agreed that VITOM enhanced their ability to perform their job and improved the surgical process. Unexpectedly, the scrub techs and nurses perceived more value and utility of VITOM, presumably because it provides them a view of the operative field that would otherwise be unavailable to them. Team members rated perceptions of image quality highly and workload generally satisfactory. Not surprisingly, setup time decreased with team experience and multivariable modeling showed significant correlations with surgeon and surgical tech experience, but not circulating nurse. An important finding was that surgeon neck discomfort was reduced with use of VITOM alone for magnification, compared with use of loupes and VITOM. The most likely explanation for these findings is improved posture with the neck at a neutral position when viewing the VITOM images, compared with neck flexion with loupes, and thus, a less favorable ergonomic position.

CONCLUSION

This study suggests that there may be small drawbacks associated with VITOM use initially, but these reduce with increased experience and benefit both the surgeon and the rest of the team.

Advantages of a Warfarin Protocol for Long-term Care Pharmacists: a Retrospective Cohort Study

Background

Warfarin is an anticoagulant prescribed to 12% of long-term care residents to reduce the risk of thrombo-embolism. This study used indicators to compare warfarin management by pharmacists to usual care.

Methods

This was a retrospective cohort study comparing a pharmacist-managed warfarin protocol with usual care of qualified warfarin recipients at long-term care facilities (two protocol, one control) in Calgary, Alberta. We compared the proportion of international normalized ratio (INR) tests in the range 2.0 to 3.0, time in range, number of tests, and frequency of bleeding at protocol and control sites. Our primary outcome, time in INR therapeutic range, is an indicator for assuring care quality. A cross-sectional survey at these sites compared health professionals’ perceptions of workload and effectiveness of warfarin management.

Results

Of the 197 residents’ charts reviewed in the study period, those on protocol had 45.0 INR tests while those on usual care had 52.7 tests (p = .034, 95% CI for the difference: 0.6 to 14.6 INR tests). No significant difference was found for time in therapeutic range, number of tests in range, or major bleeding events. Of 178 health professionals surveyed, those from protocol facilities were more satisfied with warfarin management (p = .013). Workload and safety were perceived similarly at all sites.

Interpretation

Our results suggest that a pharmacist-managed warfarin protocol is as effective as usual care and has advantages pertaining to work satisfaction, knowledge of drug interactions, consistent documentation, and fewer INR tests. Further research on teamwork and coagulation management in long-term care facilities is recommended.

Can You Multitask? Evidence and Limitations of Task Switching and Multitasking in Emergency Medicine

Emergency physicians work in a fast-paced environment that is characterized by frequent interruptions and the expectation that they will perform multiple tasks efficiently and without error while maintaining oversight of the entire emergency department. However, there is a lack of definition and understanding of the behaviors that constitute effective task switching and multitasking, as well as how to improve these skills. This article reviews the literature on task switching and multitasking in a variety of disciplines-including cognitive science, human factors engineering, business, and medicine-to define and describe the successful performance of task switching and multitasking in emergency medicine. Multitasking, defined as the performance of two tasks simultaneously, is not possible except when behaviors become completely automatic; instead, physicians rapidly switch between small tasks. This task switching causes disruption in the primary task and may contribute to error. A framework is described to enhance the understanding and practice of these behaviors.

Interruptions in the wild: Development of a sociotechnical systems model of interruptions in the emergency department through a systematic review

Interruptions are unavoidable in the "interrupt driven" Emergency Department (ED). A critical review and synthesis of the literature on interruptions in the ED can offer insight into the nature of interruptions in complex real-world environments. Fifteen empirical articles on interruptions in the ED were identified through database searches. Articles were reviewed, critiqued, and synthesized. There was little agreement and several gaps in conceptualizing sociotechnical system factors, process characteristics, and interruption outcomes. While multiple outcomes of interruptions were mentioned, few were measured, and the relationship between multiple outcomes was rarely assessed. Synthesizing the literature and drawing on ergonomic concepts, we present a sociotechnical model of interruptions in complex settings that motivates new directions in research and design. The model conceptualizes interruptions as a process, not a single event, that occurs within and is shaped by an interacting socio-technical system and that results in a variety of interrelated outcomes.

Assessing electronic health record systems in emergency departments: Using a decision analytic Bayesian model

In the last decade, health providers have implemented information systems to improve accuracy in medical diagnosis and decision-making. This article evaluates the impact of an electronic health record on emergency department physicians' diagnosis and admission decisions. A decision analytic approach using a decision tree was constructed to model the admission decision process to assess the added value of medical information retrieved from the electronic health record. Using a Bayesian statistical model, this method was evaluated on two coronary artery disease scenarios. The results show that the cases of coronary artery disease were better diagnosed when the electronic health record was consulted and led to more informed admission decisions. Furthermore, the value of medical information required for a specific admission decision in emergency departments could be quantified. The findings support the notion that physicians and patient healthcare can benefit from implementing electronic health record systems in emergency departments.

Interruptions of Trauma Resuscitations for Radiographic Procedures

BACKGROUND

Although x-ray studies provide important diagnostic information during trauma resuscitations, they may also lead to significant interruptions in care.

OBJECTIVES

We sought to determine the frequency and duration of interruptions for chest x-ray studies (CXR) and pelvic x-ray studies (PXR) and the frequency of lead apron use among providers who exited trauma rooms during resuscitation.

METHODS

Using a convenience sampling method, we conducted a prospective, observational study from August 2013 to March 2014, enrolling adult trauma patients at a Level I trauma center who received CXR and PXR in the first 30 min of evaluation. An observer stood outside resuscitation rooms and recorded the time elapsed from the first provider exiting the room to the last provider returning. We recorded how many exiting providers wore lead aprons and whether unused aprons were available.

RESULTS

Of the 156 trauma cases observed, 67.3% were of male patients with a mean age of 52 years (interquartile range [IQR] 34-67 years); 97.4% (184/189) of radiographs resulted in interruptions of trauma evaluation. Mean and median interruption times were 67 s and 50 s, respectively (IQR 25-95) for CXR; 37 s and 27 s, respectively (IQR 16-43) for PXR; and 160 s and 180 s, respectively (IQR 120-180) for combined CXR/PXR. A mean of 3.5 providers (IQR 3-5) left the immediate bedside and exited the room during x-ray studies. Most (91%) providers leaving the room were not wearing lead aprons, and extra aprons were available in the room 91% (167/184) of the time.

CONCLUSIONS

Radiographic procedures often result in interruptions of trauma resuscitations despite the availability of lead aprons.

Exploring Interruptions in the Wild

In the healthcare domain, interruptions to procedures have the potential to result in severe patient harm and in some cases can be fatal. However, it is difficult to determine whether this holds true for complex healthcare team environments that may not mirror the interruption anatomy studied in the laboratory. The investigation of interruptions in trauma resuscitation teams can provide insight into how these complex healthcare teams are affected by interruptions and what types of interruption management strategies are in place to mitigate potential adverse effects. The goal of this qualitative inquiry was to determine how interruptions are experienced and managed in the dynamic environment of trauma resuscitation. The results have provided the first insights into interrupted task performance in a complex healthcare team environment.

Workflow interruptions and mental workload in hospital pediatricians: an observational study

Background

Pediatricians’ workload is increasingly thought to affect pediatricians’ quality of work life and patient safety. Workflow interruptions are a frequent stressor in clinical work, impeding clinicians’ attention and contributing to clinical malpractice. We aimed to investigate prospective associations of workflow interruptions with multiple dimensions of mental workload in pediatricians during clinical day shifts.

Methods

In an Academic Children’s Hospital a prospective study of 28 full shift observations was conducted among pediatricians providing ward coverage. The prevalence of workflow interruptions was based on expert observation using a validated observation instrument. Concurrently, Pediatricians’ workload ratings were assessed with three workload dimensions of the well-validated NASA-Task Load Index: mental demands, effort, and frustration.

Results

Observed pediatricians were, on average, disrupted 4.7 times per hour. Most frequent were interruptions by colleagues (30.2%), nursing staff (29.7%), and by telephone/beeper calls (16.3%). Interruption measures were correlated with two workload outcomes of interest: frequent workflow interruptions were related to less cognitive demands, but frequent interruptions were associated with increased frustration. With regard to single sources, interruptions by colleagues showed the strongest associations to workload.

Conclusions

The findings provide insights into specific pathways between different types of interruptions and pediatricians’ mental workload. These findings suggest further research and yield a number of work and organization re-design suggestions for pediatric care.

Effects of electronic emergency-department whiteboards on clinicians' time distribution and mental workload

Whiteboards are a central tool at emergency departments. We investigate how the substitution of electronic for dry-erase whiteboards affects emergency department clinicians' mental workload and distribution of their time. With the electronic whiteboard, physicians and nurses spend more of their time in the work areas where other clinicians are present and whiteboard information is permanently displayed, and less in the patient rooms. Main reasons for these changes appear to be that the electronic whiteboard facilitates better timeouts and handovers. Physicians and nurses are, however, in the patient rooms for longer periods at a time, suggesting a more focused patient contact. The physicians' mental workload has increased during timeouts, whereas the nurses' mental workload has decreased at the start of shifts when they form an overview of the emergency department. Finally, the secretaries, but neither physicians nor nurses, access whiteboard information on computers other than the permanent displays.