Interruptions in healthcare: Modeling dynamic processes and effects at a team level

Interruptions are associated with increases in medical errors amongst healthcare professionals, yet interventions to reduce interruptions have not been widely successful. While interruptions can be problematic for the interruptee, they may be necessary for the interrupter to maintain patient safety. To understand the emergent effects of interruptions within a dynamic environment, we develop a computational model that describes how nurses make decisions about interruptions and the effects those decisions have at a team level. Simulations reveal the dynamic interplay between urgency, task importance, the cost of being interrupted and team efficiency, depending on the consequences of clinical or procedural error, and shed light on the ways that the risks from interruptions can be better managed.

Examining the impact of an asynchronous communication platform versus existing communication methods: an observational study

BACKGROUND

Healthcare systems revolve around intricate relations between humans and technology. System efficiency depends on information exchange that occur on synchronous and asynchronous platforms. Traditional synchronous methods of communication may pose risks to workflow integrity and contribute to inefficient service delivery and medical care.

AIM

To compare synchronous methods of communication to Medic Bleep, an instant messaging asynchronous platform, and observe its impact on clinical workflow, quality of work life and associations with patient safety outcomes and hospital core operations.

METHODS

Cohorts of healthcare professionals were followed using the Time Motion Study methodology over a 2-week period, using both the asynchronous platform and the synchronous methods like the non-cardiac pager. Questionnaires and interviews were conducted to identify staff attitudes towards both platforms.

RESULTS

A statistically significant figure (p<0.01) of 20.1 minutes' reduction in average task completion was seen with asynchronous communication, saving 58.8% of time when compared with traditional synchronous methods. In subcategory analysis for staff: doctors, nurses and midwifery categories, a p value of <0.0495 and <0.01 were observed; a mean time reduction with statistical significance was also seen in specific task efficiencies of 'To-Take-Out (TTO), patient review, discharge & patient transfer and escalation of care & procedure'. The platform was favoured with an average Likert value of 8.7; 67% found it easy to implement.

CONCLUSION

The asynchronous platform improved clinical communication compared with synchronous methods, contributing to efficiencies in workflow and may positively affect patient care.

Predictability of Interruptions During Medication Administration With Related Behavioral Management Strategies

The aim of this qualitative study was to examine the nature of interruptions during medication administration. Focus groups were conducted with medical/surgical nurses (n = 15), critical care nurses (n = 13), and nurse managers/educators/specialists (n = 6). Most interruptions (78%) were predictable. Nurse-adopted strategies included blocking, engaging, mediating, multitasking, and preventing. Educational content was developed that relates behavioral strategies to respond to predictable and unpredictable interruptions.

Measuring the relationship between interruptions, multitasking and prescribing errors in an emergency department: a study protocol

INTRODUCTION

Interruptions and multitasking are frequent in clinical settings, and have been shown in the cognitive psychology literature to affect performance, increasing the risk of error. However, comparatively less is known about their impact on errors in clinical work. This study will assess the relationship between prescribing errors, interruptions and multitasking in an emergency department (ED) using direct observations and chart review.

METHODS AND ANALYSIS

The study will be conducted in an ED of a 440-bed teaching hospital in Sydney, Australia. Doctors will be shadowed at proximity by observers for 2 h time intervals while they are working on day shift (between 0800 and 1800). Time stamped data on tasks, interruptions and multitasking will be recorded on a handheld computer using the validated Work Observation Method by Activity Timing (WOMBAT) tool. The prompts leading to interruptions and multitasking will also be recorded. When doctors prescribe medication, type of chart and chart sections written on, along with the patient's medical record number (MRN) will be recorded. A clinical pharmacist will access patient records and assess the medication orders for prescribing errors. The prescribing error rate will be calculated per prescribing task and is defined as the number of errors divided by the number of medication orders written during the prescribing task. The association between prescribing error rates, and rates of prompts, interruptions and multitasking will be assessed using statistical modelling.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the hospital research ethics committee. Eligible doctors will be provided with written information sheets and written consent will be obtained if they agree to participate. Doctor details and MRNs will be kept separate from the data on prescribing errors, and will not appear in the final data set for analysis. Study results will be disseminated in publications and feedback to the ED.

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.

Hospital paediatricians' workflow interruptions, performance, and care quality: a unit-based controlled intervention

OBJECTIVE

Frequent workflow interruptions jeopardise clinicians' efficiency and quality of clinical care. We sought to determine the effect of a documentation-assistant intervention. Our hypothesis was that the expected decrease of workflow interruptions enhances paediatricians' performance and simultaneously improves patients' perceived quality of care.

METHODS

This was a controlled intervention study with data collected before and after the intervention at a University Children's Hospital. For the intervention, a documentation assistant was assigned to an inpatient ward. The main outcome measures were workflow interruptions, paediatricians' performance, as well as patients' perceived quality of care. Workflow interruptions were assessed via standardised expert observations. Paediatricians' evaluated their performance in terms of productivity, quality, and efficiency. Additionally, standardised patients' reports on perceived quality of care were collected.

RESULTS

For paediatricians in the intervention ward, workflow interruptions decreased significantly from 5.2 to 3.1 disruption events per working hour (decrease in the control unit was from 3.8 to 3.1). Furthermore, paediatricians reported at follow-up significantly enhanced productivity, quality, and efficiency. Similarly, patients' ratings of care quality improved significantly over time. In multivariate analyses, we found substantial changes attributable to the intervention: for all three outcomes, we found a significant interaction effect of the intervention over study time.

CONCLUSIONS

The intervention streamlined paediatricians' workflow, improved day-to-day functioning of the ward, and enhanced organisational efficiency and delivery of paediatric care. Future studies should investigate potential influences between the reduction of workflow interruptions, paediatricians' perceived performance, and patient-related outcomes in quality and efficiency of paediatric care.

Managing competing demands through task-switching and multitasking: a multi-setting observational study of 200 clinicians over 1000 hours

OBJECTIVE

To provide a detailed characterisation of clinicians' work management strategies.

DESIGN

1002.3 h of observational data were derived from three previous studies conducted in a teaching hospital in Sydney, Australia, among emergency department (ED) doctors (n=40), ward doctors (n=57) and ward nurses (n=104). The rates of task-switching (pausing a task to handle an incoming task) and multitasking (adding a task in parallel to an existing task) were compared in each group. Random intercepts logistic regression was used to determine factors significantly associated with clinicians' use of task-switching over multitasking and to quantify variation between individual clinicians.

RESULTS

Task-switching rates were higher among ED doctors (6.0 per hour) than ward staff (2.2 and 1.8 per hour for doctors and nurses, respectively) and vice versa for multitasking rates (9.2 vs 17.3 and 14.1 per hour). Clinicians' strategy use was significantly related to the nature and complexity of work and to the person they were working with. In some settings, time of day, day of the week or previous chosen strategy affected a clinician's strategy. Independent of these factors, there was significant variation between individual clinicians in their use of strategies in a given situation (ED doctors p=0.04, ward staff p=0.03).

CONCLUSIONS

Despite differences in factors associated with work management strategy use among ED doctors, ward doctors and ward nurses, clinicians in all settings appeared to prioritise certain types of tasks over others. Documentation was generally given low priority in all groups, while the arrival of direct care tasks tended to be treated with high priority. These findings suggest that considerations of safety may be implicit in task-switching and multitasking decisions. Although these strategies have been cast in a negative light, future research should consider their role in optimising competing quality and efficiency demands.