Learning Interrupted: Educational Impact of Interruptions on Surgical Residents

OBJECTIVE

The complex workflow of surgical residents in the workplace-based learning environment makes interruptions an unavoidable aspect of clinical work. Interruptions have been shown to affect cognitive load, surgical performance, and medical error. The purpose of this study was to describe the effects of interruptions on surgical resident education.

DESIGN

Junior residents were observed by 2 trained observers using time-motion methodology between September 2018-August 2019. Interruptions were identified and coded retroactively based on predefined criteria. We captured key features of interruptions including frequency, duration, task interrupted, outcome, and learner perceived educational value.

SETTING

This study took place at London Health Sciences Centre in London, Ontario, Canada, a tertiary level academic health care center associated with the Schulich School of Medicine & Dentistry at Western University.

PARTICIPANTS

Junior residents on a General Surgery service were eligible for participation. Participation was voluntary. 8 residents were observed over 24 clinical periods.

RESULTS

A total of 278.2 hours of resident workflow were observed, and 229 interruptions were recorded. Interruptions account for 57.9 minutes/day of a surgical resident (SD = 60.7). Interruptions occur at a frequency of 0.82 interruptions/hour. Disruptive interruptions, that interfere with the continuation or completion of the original task, occur at a frequency of 0.11 interruptions/hour. Disruptive interruptions occurred at a higher frequency of 0.34 interruptions/hour during periods of feedback, coaching and informal teaching.

DISCUSSION

We observed that tasks of higher learner perceived educational value are often interrupted by tasks of lower learner perceived education value. Valuable educational experiences such as feedback, coaching and informal teaching are interrupted at a greater rate and experience disruptions at a disproportionate rate. We identified feedback, coaching and informal teaching as an education task vulnerable to disruptive interruptions that would benefit from interventions targeted toward preventing interruption. Suggested interventions include "formalizing" feedback, coaching and informal teaching.

It's like sending a message in a bottle: A qualitative study of the consequences of one-way communication technologies in hospitals

OBJECTIVE

We examine how physicians and nurses use available communication technologies and identify the implications for communication and patient care based on the theory of workarounds.

MATERIALS AND METHODS

We conducted a qualitative study at 4 U.S. hospitals during 2017. Researchers spent 2 weeks at each hospital conducting unit-based observation, shadowing, interviews, and focus groups with nurses and physicians. Using an iterative process, we inductively coded and thematically analyzed data to derive preliminary themes. The theory of workarounds provides an organizational lens on workarounds, consisting of 5 components: antecedents, types, effects, managerial stance, and organizational challenges of workarounds. The first 3 components of the theory helped us to organize and explain our findings.

RESULTS

Communication technologies consisted of pagers and telephones. Antecedents to workarounds included one-way information flow, differential access related to differences in technology types, and technology mismatch. Types of workarounds included bypassing a variety of obstacles and substituting for unavailable resources. Direct effects of workarounds included pager fatigue, interruptions in patient care, and potential errors.

DISCUSSION

One-way communication technologies created an environment where workarounds could flourish. By placing results within the context of the theory of workarounds, we extend what we know about why and how workarounds develop, and offer strategies to minimize workarounds' adverse effects.

CONCLUSIONS

Through the theory of workarounds, we see that there is a trajectory to workarounds with potential consequences for clinicians and patients. Two-way communication technologies could minimize workarounds and gaps in information exchange, and reduce unnecessary interruptions and the potential for adverse events.

Nighttime Calls, Pages, and Interruptions to the On-Call Surgery Resident

BACKGROUND

Communication is a keystone to good medical practice. At night, as physician numbers decrease, frequent, nonurgent interruptions have shown to disrupt patient care and impact resident/physician wellness. Potentially, interruptions can lead to an increase in medical errors. The frequency and activities interrupted during night calls have not been fully described.

METHODS

For a period of 44 days (August through September), all calls and pages received during the 12-hour night call session were documented. Calls were analyzed by caller, urgency, need for intervention, and resident interrupted by the communication.

RESULTS

A total of 494 communications were identified with a mean of 10 calls per shift (IQR 7-14). Communications lasted a mean of 2.7 +/- 2.9 minutes. Direct calls occurred in 78% and pages in 22% of the cases. From the non-ED calls (n = 335), most of them came from nursing staff (85%), followed by other specialties (12%). Five percent of the calls were directed to the wrong service. Communications occurred during charting (41%), patient assessment (33%), interrupted resident's sleep (12%), or during a surgical procedure (6%). Communication required no action in 47% of the cases. A physician order was needed in 41%, while bedside clinical assessment was required in 12% of the calls.

CONCLUSIONS

Communications are common at night, but most did not require clinical assessment. A large portion of communications interrupted direct patient care. An opportunity exists to eliminate nonproductive communications and improve the quality of medical education.

"Surgery interrupted": The effect of multitasking on cognitive and technical tasks in medical students

INTRODUCTION

Today's medical learners are Millennials, and reportedly, multitasking pros. We aim to evaluate effect of multitasking on cognitive and technical skills.

MATERIALS AND METHODS

16 medical students completed a mock page and laceration closure separately on day 1 and day 13, and in parallel on day 14. Suturing was graded using GRS and mock pages scored. Total time, suturing and loading times, and percent correct on mock page were compared.

RESULTS

Percent correct on mock page improved from days 1-13 and 14 (p < 0.01 and 0.04). GRS improved from days 1-13 and 14 (p = 0.04 and <0.01). Total time suturing was similar on all days. However, time suturing during the mock page on day 14 was prolonged compared to before mock page (p = 0.01).

CONCLUSIONS

Medical students can complete cognitive and technical tasks in parallel, without compromising acceptability. However, multitasking results in longer times to complete the complex component of the technical task.

Defining Communication Improvement Needs in General Surgery: An Analysis of Pages, Communications, Patterns, and Content☆?>

OBJECTIVE

To describe patterns of pages communication to general surgery (GS) residents, identify the need for and develop strategies to improve interprofessional communication.

DESIGN

Retrospective cohort study.

SETTING

General surgery (GS) service at a tertiary care academic institution, Sunnybrook Health Sciences Centre, in Toronto, Ontario, Canada.

PARTICIPANTS

All pages sent to GS residents over 4 weeks at an academic institution. Timing, training level of receiver and content of pages were captured.

RESULTS

Communication priority was assigned by 2 independent reviewers-low (121+ min), medium (31-120min), high (6-30min), and immediate (0-5min) priority. Overall, 2 independent reviewers analyzed pages' content through an inductive process, and generated themes. Of 2025 pages retrieved, 963 (47.5%) contained exclusively a call back number. A median of 74 pages per day (range: 43-116) were received, with median page interval of 9.4 minutes (range: 0-640). Junior residents received 79.5% of pages. Timing of the pages was 43.9% weekday shift, 31.8% weeknight shift, and 24.3% weekend call. Communication priority was deemed low for 35.4% of pages, medium for 32.3%, high for 12.4%, and immediate for 0.7%. Content analysis of 1062 pages generated 5 major themes: nonurgent medical issue (54.0%), administrative (15.3%), communication (13.5%), emergencies (4.8%), and GS consultation requests (4.0%). Priority and content of pages varied according to training level and page timing.

CONCLUSIONS

Pages to GS residents were frequent and most often of low priority. They were seldom related to urgent medical matters. Education and new communication strategies are warranted to reduce low priority pages.

Improving neurosurgical communication and reducing risk and registrar burden using a novel online database referral platform

OBJECTIVES

Documentation of urgent referrals to neurosurgical units and communication with referring hospitals is critical for effective handover and appropriate continuity of care within a tertiary service. Referrals to our neurosurgical unit were audited and we found that the majority of referrals were not documented and this led to more calls to the on-call neurosurgery registrar regarding old referrals. We implemented a new referral system in an attempt to improve documentation of referrals, communication with our referring hospitals and to professionalise the service we offer them.

METHODS

During a 14-day period, number of bleeps, missed bleeps, calls discussing new referrals and previously processed referrals were recorded. Whether new referrals were appropriately documented and referrers received a written response was also recorded. A commercially provided secure cloud-based data archiving telecommunications and database platform for referrals was subsequently introduced within the Trust and the questionnaire repeated during another 14-day period 1 year after implementation.

RESULTS

Missed bleeps per day reduced from 16% (SD ± 6.4%) to 9% (SD ± 4.8%; df = 13, paired t-tests p = 0.007) and mean calls per day clarifying previous referrals reduced from 10 (SD ± 4) to 5 (SD ± 3.5; df = 13, p = 0.003). Documentation of new referrals increased from 43% (74/174) to 85% (181/210), and responses to referrals increased from 74% to 98%.

CONCLUSION

The use of a secure cloud-based data archiving telecommunications and database platform significantly increased the documentation of new referrals. This led to fewer missed bleeps and fewer calls about old referrals for the on call registrar. This system of documenting referrals results in improved continuity of care for neurosurgical patients, a significant reduction in risk for Trusts and a more efficient use of Registrar time.

The use of technology for urgent clinician to clinician communications: a systematic review of the literature

OBJECTIVE

Urgent clinician-clinician communications require routes of contact that are fast and dependable, and allow for the exchange of complex information. Despite the increasing focus on improving healthcare delivery systems over the past decade, few studies have examined the role of technology in clinician-clinician communication. The aim of this study was to review the literature examining the role of devices and technology in facilitating urgent clinician-clinician communication to identify critical areas for future research.

MATERIALS AND METHODS

A search of Pub Med was performed using the terms (((("Critical Care"[Mesh] OR "urgent")))) AND (((hospital communication systems[MeSH Terms]) OR health communication[MeSH Terms]) OR interdisciplinary communication[MeSH Terms]). Commentaries and editorials were excluded.

RESULTS

The initial search returned 272 articles, which were reviewed to identify articles describing: (1) the role of technological support or devices in clinician-clinician communication, (2) technology-based interventions that improved clinician-to-clinician communication in hospitals or acute care facilities related to critically ill patients, or (3) critical information exchange. A total of 16 articles were included in the final review. These were grouped into three categories: alphanumeric pagers, cellular and smart telephones, and novel uses of technology.

DISCUSSION

Breakdowns in clinician-clinician communication are complex and cannot be solved through the implementation of devices or technologically advanced systems alone. It is essential to understand the correlation between emerging technologies, a demanding workload, and clinician-clinician interaction. Enhanced communication of clinical ideas, opportunities for team discussion, and a sense of partnership and support require not just increased information, but enhanced delivery.