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Anastas T, Wu W, Burgess DJ, Stewart JC, Salyers MP, Kroenke K, Hirsh AT. The Impact of Patient Race, Patient Socioeconomic Status, and Cognitive Load of Physician Residents and Fellows on Chronic Pain Care Decisions. THE JOURNAL OF PAIN 2024; 25:104480. [PMID: 38246252 PMCID: PMC11180591 DOI: 10.1016/j.jpain.2024.01.345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 01/12/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024]
Abstract
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.
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Affiliation(s)
- Tracy Anastas
- Department of Psychology, Indiana University Indianapolis
- Department of Psychiatry and Behavioral Sciences, University of Washington
- Department of Family Medicine, University of Washington
| | - Wei Wu
- Department of Psychology, Indiana University Indianapolis
| | - Diana J. Burgess
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Medical Center
- University of Minnesota Medical School
| | | | | | - Kurt Kroenke
- Department of Medicine, Indiana University School of Medicine
- Regenstrief Institute, Inc
| | - Adam T. Hirsh
- Department of Psychology, Indiana University Indianapolis
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Mostafa R, El-Atawi K. Strategies to Measure and Improve Emergency Department Performance: A Review. Cureus 2024; 16:e52879. [PMID: 38406097 PMCID: PMC10890971 DOI: 10.7759/cureus.52879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 02/27/2024] Open
Abstract
Emergency Departments (EDs) globally face escalating challenges such as overcrowding, resource limitations, and increased patient demand. This study aims to identify and analyze strategies to enhance the structural performance of EDs, with a focus on reducing overcrowding, optimizing resource allocation, and improving patient outcomes. Through a comprehensive review of the literature and observational studies, the research highlights the effectiveness of various approaches, including triage optimization, dynamic staffing, technological integration, and strategic resource management. Key findings indicate that tailored strategies, such as implementing advanced triage protocols and leveraging telemedicine, can significantly reduce wait times and enhance patient throughput. Furthermore, evidence suggests that dynamic staffing models and the integration of cutting-edge diagnostic tools contribute to operational efficiency and improved quality of care. These strategies, when combined, offer a multifaceted solution to the complex challenges faced by EDs, promising better patient care and satisfaction. The study underscores the need for a comprehensive approach, incorporating both organizational and technological innovations, to address the evolving needs of emergency healthcare.
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Affiliation(s)
- Reham Mostafa
- Department of Emergency Medicine, Al Zahra Hospital Dubai (AZHD), Dubai, ARE
| | - Khaled El-Atawi
- Pediatrics/ Neonatal Intensive Care Unit, Latifa Women and Children Hospital, Dubai, ARE
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Cildoz M, Ibarra A, Mallor F. Acuity-based rotational patient-to-physician assignment in an emergency department using electronic health records in triage. Health Informatics J 2023; 29:14604582231167430. [PMID: 37068379 DOI: 10.1177/14604582231167430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
Emergency department (ED) operational metrics generated by a new acuity-based rotational patient-to-physician assignment (ARPA) algorithm are compared with those obtained with a simple rotational patient assignment (SRPA) system aimed only at an equitable patient distribution. The new ARPA method theoretically guarantees that no two physicians' assigned patient loads can differ by more than one, either partially (by acuity levels) or in total; whereas SRPA guarantees only the latter. The performance of the ARPA method was assessed in practice in the ED of the main public hospital (Hospital Compound of Navarra) in the region of Navarre in Spain. This ED attends over 140 000 patients every year. Data analysis was conducted on 9,063 ED patients in the SRPA cohort, and 8,892 ED patients in the ARPA cohort. The metrics of interest are related both to patient access to healthcare and physician workload distribution: patient length of stay; arrival-to-provider time; ratio of patients exceeding the APT target threshold; and range of assigned patients across physicians by priority levels. The transition from SRPA to ARPA is associated with improvements in all ED operational metrics. This research demonstrates that ARPA is a simple and useful strategy for redesigning front-end ED processes.
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Affiliation(s)
- Marta Cildoz
- Institute of Smart Cities, Public University of Navarre, Pamplona, Spain
| | | | - Fermin Mallor
- Institute of Smart Cities, Public University of Navarre, Pamplona, Spain
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Li D, Hu Y, Liu S, Lu C, Zhang Y, Zhou J, Li J, Zhang Z. Developing an Integrated Evaluation Model for Physician Comprehensive Workload Tethered to Outpatient Practice: An Empirical Study From China. Front Public Health 2022; 10:847613. [PMID: 35664107 PMCID: PMC9162480 DOI: 10.3389/fpubh.2022.847613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background Previous studies, often simply using either objective workload or mental workload as a measure of physician workload in various healthcare settings might have failed to comprehensively reflect the real workload among physicians. Despite this, there is little research that further explores a comprehensive workload evaluation framework with the integration of objective workload and mental workload to describe their comprehensive workload. Methods A comprehensive evaluation framework for physician workload was proposed based on the combination of objective workload and task-level mental workload also with the consideration of quality of provided medical services and served patient complexity; and accordingly, an integrated evaluation model for physician comprehensive workload (PCW) tethered to outpatient practice was developed and further applied to perform a PCW analysis using cross-sectional data on outpatient workload of 1,934 physicians mainly from 24 hospitals in 6 provinces in Eastern, Central, and Western China. Multiple linear regression and multinomial logistic regression analyses were established to identify significant factors influencing the PCW. Results Overall, the average score of PCW tethered to outpatient practice Chinese physicians experienced was 811.30 (SD=494.98) with concentrating on between 200 and 1,200. Physicians who were female, from Eastern or Western China, and those who worked >60 h per week and longer outpatient hours per week were more likely to experience a higher PCW. 11.2% of participating physicians were identified as very high PCW physicians, compared with 11.6% as low PCW physicians, 45.5% as medium PCW physicians and 30.7% as high PCW physicians. Those who were female, older, from Western China, those who had lower educational levels, lower professional titles and longer working years in the current institution, and those who worked in tertiary A hospitals and Internal or Surgical, and worked >60 h per week and longer outpatient hours per week were more likely to be very high PCW physicians. Conclusions Our work has a potential application for comprehensively assessing physician workload tethered to outpatient practice and could provide a solid foundation for hospital managers to further accurately determine and identify physicians with high workload, who would otherwise be missed in either objective workload or mental workload.
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Affiliation(s)
- Dehe Li
- 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
- *Correspondence: Yinhuan Hu
| | - Sha Liu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chuntao Lu
- Jingmen No. 2 People's Hospital, Jingmen, China
| | - Yeyan Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jinghan Zhou
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiayi Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zemiao Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Lukan J, Bolliger L, Pauwels NS, Luštrek M, Bacquer DD, Clays E. Work environment risk factors causing day-to-day stress in occupational settings: a systematic review. BMC Public Health 2022; 22:240. [PMID: 35123449 PMCID: PMC8818147 DOI: 10.1186/s12889-021-12354-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 11/29/2021] [Indexed: 01/24/2023] Open
Abstract
Abstract
Background
While chronic workplace stress is known to be associated with health-related outcomes like mental and cardiovascular diseases, research about day-to-day occupational stress is limited. This systematic review includes studies assessing stress exposures as work environment risk factors and stress outcomes, measured via self-perceived questionnaires and physiological stress detection. These measures needed to be assessed repeatedly or continuously via Ecological Momentary Assessment (EMA) or similar methods carried out in real-world work environments, to be included in this review. The objective was to identify work environment risk factors causing day-to-day stress.
Methods
The search strategies were applied in seven databases resulting in 11833 records after deduplication, of which 41 studies were included in a qualitative synthesis. Associations were evaluated by correlational analyses.
Results
The most commonly measured work environment risk factor was work intensity, while stress was most often framed as an affective response. Measures from these two dimensions were also most frequently correlated with each other and most of their correlation coefficients were statistically significant, making work intensity a major risk factor for day-to-day workplace stress.
Conclusions
This review reveals a diversity in methodological approaches in data collection and data analysis. More studies combining self-perceived stress exposures and outcomes with physiological measures are warranted.
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Linton E, Souffront K, Gordon L, Loo GT, Genes N, Glassberg J. System Level Informatics to Improve Triage Practices for Sickle Cell Disease Vaso-Occlusive Crisis: A Cluster Randomized Controlled Trial. J Emerg Nurs 2021; 47:742-751.e1. [PMID: 34301422 PMCID: PMC9924131 DOI: 10.1016/j.jen.2021.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 04/28/2021] [Accepted: 05/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND National Heart Lung and Blood Institute guidelines for the treatment of vaso-occlusive crisis among people with sickle cell disease in the emergency department recommend assigning an emergency severity index of 2 at triage. However, patients with sickle cell disease often do not receive guideline-concordant care at triage. To address this gap, a decision support tool was developed, in the form of a text banner on the triage page in the electronic health record system, visible to triage nurses. METHODS A prospective quality improvement initiative was designed where the emergency severity index clinical decision support tool was deployed to a stratified random sample of emergency department triage nurses to receive the banner (n = 24) or not to receive the banner (n = 27), reminding them to assign the patient to emergency severity index category 2. The acceptability of the emergency severity index clinical decision support tool was evaluated with the Ottawa Acceptability of Decision Rules Instrument. Descriptive and bivariate (chi-square test) statistics were used to characterize the study's primary outcome, proportion of visits assigned an emergency severity index of 2 or higher. A generalized linear mixed model with clustering at the level of the triage nurse was performed to test the association between the banner intervention and triage practices. RESULTS A total of 384 ED visits were included for analysis. Before study initiation, the percentage of sickle cell disease patients' visits with the proper emergency severity index assignment at triage was 37.04%. After initiation, the proportion of sickle cell disease patients' visits with an emergency severity index of 2 or higher triaged by nurses in the intervention group was markedly higher in the intervention group than in the control group (64.95% vs 35.05%; χ2 = 8.79, P ≤ .003). Accounting for clustering by nurse, the odds ratio for proper triage emergency severity index assignment was 3.22 (95% confidence interval 1.17-8.85; P ≤ .02) for the intervention versus control. Surveyed triage nurses reported the emergency severity index clinical decision support tool to be moderately acceptable (nurses' mean Ottawa Acceptability of Decision Rules Instrument scores ranged from 4.13 to 4.90 on the 6-point scale; n = 11). There were no differences in ED experience outcomes including time to first analgesic or length of stay between the control and intervention groups. CONCLUSION Substantial improvements in triage guideline concordance were achieved and sustained without direct nursing education.
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Affiliation(s)
- Elizabeth Linton
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kimberly Souffront
- Department of Emergency Medicine; Mount Sinai Department of Nursing Center for Nursing Research & Innovation, Icahn School of Medicine at Mount Sinai Hospital, New York, NY
| | - Lauren Gordon
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai Hospital, New York, NY
| | - George T. Loo
- Department of Emergency Medicine; Population Health Science and Policy, Ichan School of Medicine at Mount Sinai, New York, NY
| | - Nicholas Genes
- Department of Emergency Medicine; Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai Hospital, New York, NY
| | - Jeffrey Glassberg
- For correspondence, write: Jeffrey Glassberg, MD, MA; , Twitter: @DRGlassberg
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Abstract
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.
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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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Fishbein D, Nambiar S, McKenzie K, Mayorga M, Miller K, Tran K, Schubel L, Agor J, Kim T, Capan M. Objective measures of workload in healthcare: a narrative review. Int J Health Care Qual Assur 2020; 33:1-17. [PMID: 31940153 DOI: 10.1108/ijhcqa-12-2018-0288] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Workload is a critical concept in the evaluation of performance and quality in healthcare systems, but its definition relies on the perspective (e.g. individual clinician-level vs unit-level workload) and type of available metrics (e.g. objective vs subjective measures). The purpose of this paper is to provide an overview of objective measures of workload associated with direct care delivery in tertiary healthcare settings, with a focus on measures that can be obtained from electronic records to inform operationalization of workload measurement. DESIGN/METHODOLOGY/APPROACH Relevant papers published between January 2008 and July 2018 were identified through a search in Pubmed and Compendex databases using the Sample, Phenomenon of Interest, Design, Evaluation, Research Type framework. Identified measures were classified into four levels of workload: task, patient, clinician and unit. FINDINGS Of 30 papers reviewed, 9 used task-level metrics, 14 used patient-level metrics, 7 used clinician-level metrics and 20 used unit-level metrics. Key objective measures of workload include: patient turnover (n=9), volume of patients (n=6), acuity (n=6), nurse-to-patient ratios (n=5) and direct care time (n=5). Several methods for operationalization of these metrics into measurement tools were identified. ORIGINALITY/VALUE This review highlights the key objective workload measures available in electronic records that can be utilized to develop an operational approach for quantifying workload. Insights gained from this review can inform the design of processes to track workload and mitigate the effects of increased workload on patient outcomes and clinician performance.
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Affiliation(s)
- Daniela Fishbein
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Siddhartha Nambiar
- Edward P. Fitts Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, North Carolina, USA
| | - Kendall McKenzie
- Edward P. Fitts Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, North Carolina, USA
| | - Maria Mayorga
- Edward P. Fitts Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, North Carolina, USA
| | - Kristen Miller
- National Center for Human Factors in Healthcare, MedStar Health, Washington, District of Columbia, USA
| | - Kevin Tran
- LeBow College of Business, Drexel University, Philadelphia, Pennsylvania, USA
| | - Laura Schubel
- National Center for Human Factors in Healthcare, MedStar Health, Washington, District of Columbia, USA
| | - Joseph Agor
- School of Mechanical, Industrial and Manufacturing Engineering, Oregon State University, Corvallis, Oregon, USA
| | - Tracy Kim
- National Center for Human Factors in Healthcare, MedStar Health, Washington, District of Columbia, USA
| | - Muge Capan
- LeBow College of Business, Drexel University, Philadelphia, Pennsylvania, USA
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France DJ, Levin S, Ding R, Hemphill R, Han J, Russ S, Aronsky D, Weinger M. Factors Influencing Time-Dependent Quality Indicators for Patients With Suspected Acute Coronary Syndrome. J Patient Saf 2020; 16:e1-e10. [PMID: 26756723 PMCID: PMC4940339 DOI: 10.1097/pts.0000000000000242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Rapid risk stratification and timely treatment are critical to favorable outcomes for patients with acute coronary syndrome (ACS). Our objective was to identify patient and system factors that influence time-dependent quality indicators (QIs) for patients with unstable angina/non-ST elevation myocardial infarction (NSTEMI) in the emergency department (ED). METHODS A retrospective, cohort study was conducted during a 42-month period of all patients 24 years or older suspected of having ACS as defined by receiving an electrocardiogram and at least 1 cardiac biomarker test. Cox regression was used to model the effects of patient characteristics, ancillary service use, staffing provisions, equipment availability, and ED and hospital crowding on ACS QIs. RESULTS Emergency department adherence rates to national standards for electrocardiogram readout time and biomarker turnaround time were 42% and 37%, respectively. Cox regression models revealed that chief complaints without chest pain and the timing of stress testing and medication administration were associated with the most significant delays. CONCLUSIONS Patient and system factors both significantly influenced QI times in this cohort with unstable angina/NSTEMI. These results illustrate both the complexity of diagnosing patients with NSTEMI and the competing effects of clinical and system factors on patient flow through the ED.
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Affiliation(s)
- Daniel J France
- From the Department of Anesthesiology, Vanderbilt Medical Center, Nashville, Tennessee
| | - Scott Levin
- Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ru Ding
- Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Robin Hemphill
- National Center for Patient Safety, Veterans Affairs, Ann Arbor, Michigan
| | - Jin Han
- Department of Emergency Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Stephan Russ
- Department of Emergency Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Dominik Aronsky
- Department of Emergency Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Matt Weinger
- From the Department of Anesthesiology, Vanderbilt Medical Center, Nashville, Tennessee
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11
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Prints M, Fishbein D, Arnold R, Stander E, Miller K, Kim T, Capan M. Understanding the perception of workload in the emergency department and its impact on medical decision making. Am J Emerg Med 2020; 38:397-399. [PMID: 31378413 DOI: 10.1016/j.ajem.2019.07.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 07/14/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
| | - Daniela Fishbein
- Sidney Kimmel Medical College, Thomas Jefferson University, USA.
| | - Ryan Arnold
- College of Medicine, Hahnemann University Hospital, Drexel University, USA.
| | - Eric Stander
- College of Medicine, Hahnemann University Hospital, Drexel University, USA.
| | - Kristen Miller
- National Center for Human Factors in Healthcare, MedStar Institute for Innovation (MI2), USA.
| | - Tracy Kim
- National Center for Human Factors in Healthcare, MedStar Institute for Innovation, MedStar Health, USA.
| | - Muge Capan
- Decision Sciences & MIS Department, LeBow College of Business, Drexel University, Gerri C. LeBow Hall, 3220 Market Street, Philadelphia, PA 19104, USA.
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12
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Keunecke JG, Gall C, Birkholz T, Moritz A, Eiche C, Prottengeier J. Workload and influencing factors in non-emergency medical transfers: a multiple linear regression analysis of a cross-sectional questionnaire study. BMC Health Serv Res 2019; 19:812. [PMID: 31699084 PMCID: PMC6836439 DOI: 10.1186/s12913-019-4638-4] [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: 04/01/2019] [Accepted: 10/14/2019] [Indexed: 11/11/2022] Open
Abstract
Background Human workload is a key factor for system performance, but data on emergency medical services (EMS) are scarce. We investigated paramedics’ workload and the influencing factors for non-emergency medical transfers. These missions make up a major part of EMS activities in Germany and are growing steadily in number. Methods Paramedics rated missions retrospectively through an online questionnaire. We used the NASA-Task Load Index (TLX) to quantify workload and asked about a variety of medical and procedural aspects for each mission. Teamwork was assessed by the Weller teamwork measurement tool (TMT). With a multiple linear regression model, we identified a set of factors leading to relevant increases or decreases in workload. Results A total of 194 non-emergency missions were analysed. Global workload was rated low (Mean = 27/100). In summary, 42.8% of missions were rated with a TLX under 20/100. TLX subscales revealed low task demands but a very positive self-perception of performance (Mean = 15/100). Teamwork gained high ratings (Mean TMT = 5.8/7), and good teamwork led to decreases in workload. Aggression events originating from patients and bystanders occurred frequently (n = 25, 12.9%) and increased workload significantly. Other factors affecting workload were the patient’s body weight and the transfer of patients with transmittable pathogens. Conclusion The workload during non-emergency medical transfers was low to very low, but performance perception was very positive, and no indicators of task underload were found. We identified several factors that led to workload increases. Future measures should attempt to better train paramedics for aggression incidents, to explore the usefulness of further technical aids in the transfer of obese patients and to reconsider standard operating procedures for missions with transmittable pathogens.
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Affiliation(s)
- Johann Georg Keunecke
- Faculty of Medicine, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.
| | - Christine Gall
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Torsten Birkholz
- Faculty of Medicine, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.,Department of Anaesthesiology, University Hospital Erlangen, Erlangen, Germany
| | - Andreas Moritz
- Faculty of Medicine, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.,Department of Anaesthesiology, University Hospital Erlangen, Erlangen, Germany
| | - Christian Eiche
- Faculty of Medicine, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.,Department of Anaesthesiology, University Hospital Erlangen, Erlangen, Germany
| | - Johannes Prottengeier
- Faculty of Medicine, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.,Department of Anaesthesiology, University Hospital Erlangen, Erlangen, Germany
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Prottengeier J, Keunecke JG, Gall C, Eiche C, Moritz A, Birkholz T. Single mission workload and influencing factors in German prehospital emergency medicine - a nationwide prospective survey of 1361emergency missions. Scand J Trauma Resusc Emerg Med 2019; 27:75. [PMID: 31419996 PMCID: PMC6698029 DOI: 10.1186/s13049-019-0650-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 07/23/2019] [Indexed: 11/10/2022] Open
Abstract
Background Workload is a major determinant of system performance and human well-being. This study aims to evaluate workload in prehospital emergency medicine on a single mission level and investigates influencing factors originating from medical scenarios, patient-provider interaction, EMS logistics and teamwork. Methods In a nationwide study, German paramedics were asked to evaluate single missions for perceived workload by completing the NASA Task-Load-Index (TLX). A variety of candidate variables were documented and tested for influence on the TLX through multivariate regression analysis. Results One thousand three hundred sixty-one emergency missions were analysed. Global workload scored in medium ranges (Median TLX 41.00/100; IQR 24.25–57.50). 263 missions achieved very low (< 20/100) and 52 missions achieved very high (> 80/100) levels of workload. Severity of distress as indicated by the NACA score (delta TLX 2.71 per 1 NACA point), execution of invasive procedures (e.g. delta TLX 8.20 for intravenous access), obese patients (delta TLX 0.05 per 1 kg of weight) and aggression incidences (e.g. delta TLX 10.54 for physical aggression), amongst others, resulted in significant increases in workload. Good teamwork decreased workload by 2.18 points per 1 point on the Weller-Teamwork Measurement Tool. Conclusion Distinct factors result in significant increases in workload for EMS paramedics. Improvements in training for certain medical scenarios, strategies against aggression events and enhancements in EMS logistics - especially for the transfer of obese patients – should be implemented and tested for their presumably positive effect on workload, EMS performance and paramedics’ well-being. Electronic supplementary material The online version of this article (10.1186/s13049-019-0650-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Johannes Prottengeier
- Department of Anaesthesiology, University Hospital Erlangen, Erlangen, Germany. .,Faculty of Medicine, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.
| | - Johann Georg Keunecke
- Faculty of Medicine, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Christine Gall
- Department of Medical Informatics Biometry and Epidemiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Christian Eiche
- Department of Anaesthesiology, University Hospital Erlangen, Erlangen, Germany.,Faculty of Medicine, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Andreas Moritz
- Department of Anaesthesiology, University Hospital Erlangen, Erlangen, Germany.,Faculty of Medicine, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Torsten Birkholz
- Department of Anaesthesiology, University Hospital Erlangen, Erlangen, Germany.,Faculty of Medicine, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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Melnick ER, Jeffery MM, Dziura JD, Mao JA, Hess EP, Platts-Mills TF, Solad Y, Paek H, Martel S, Patel MD, Bankowski L, Lu C, Brandt C, D’Onofrio G. User-centred clinical decision support to implement emergency department-initiated buprenorphine for opioid use disorder: protocol for the pragmatic group randomised EMBED trial. BMJ Open 2019; 9:e028488. [PMID: 31152039 PMCID: PMC6550013 DOI: 10.1136/bmjopen-2018-028488] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/12/2019] [Accepted: 04/24/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The goal of this trial is to determine whether implementation of a user-centred clinical decision support (CDS) system can increase adoption of initiation of buprenorphine (BUP) into the routine emergency care of individuals with opioid use disorder (OUD). METHODS A pragmatic cluster randomised trial is planned to be carried out in 20 emergency departments (EDs) across five healthcare systems over 18 months. The intervention consists of a user-centred CDS integrated into ED clinician electronic workflow and available for guidance to: (1) determine whether patients presenting to the ED meet criteria for OUD, (2) assess withdrawal symptoms and (3) ascertain and motivate patient willingness to initiate treatment. The CDS guides the ED clinician to initiate BUP and facilitate follow-up. The primary outcome is the rate of BUP initiated in the ED. Secondary outcomes are: (1) rates of receiving a referral, (2) fidelity with the CDS and (3) rates of clinicians providing any ED-initiated BUP, referral for ongoing treatment and receiving Drug Addiction Act of 2000 training. Primary and secondary outcomes will be analysed using generalised linear mixed models, with fixed effects for intervention status (CDS vs usual care), prespecified site and patient characteristics, and random effects for study site. ETHICS AND DISSEMINATION The protocol has been approved by the Western Institutional Review Board. No identifiable private information will be collected from patients. A waiver of informed consent was obtained for the collection of data for clinician prescribing and other activities. As a minimal risk implementation study of established best practices, an Independent Study Monitor will be utilised in place of a Data Safety Monitoring Board. Results will be reported in ClinicalTrials.gov and published in open-access, peer-reviewed journals, presented at national meetings and shared with the clinicians at participating sites via a broadcast email notification of publications. TRIAL REGISTRATION NUMBER NCT03658642; Pre-results.
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Affiliation(s)
- Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - James D Dziura
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jodi A Mao
- Emergency Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Erik P Hess
- Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Yauheni Solad
- Information Technology Services, Yale New-Haven Health, New Haven, Connecticut, USA
| | - Hyung Paek
- Information Technology Services, Yale New-Haven Health, New Haven, Connecticut, USA
| | - Shara Martel
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Laura Bankowski
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles Lu
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Cynthia Brandt
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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15
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Comparisons of Stress Physiology of Providers in Real-Life Resuscitations and Virtual Reality–Simulated Resuscitations. ACTA ACUST UNITED AC 2019; 14:104-112. [DOI: 10.1097/sih.0000000000000356] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Ray JM, Ahmed OM, Solad Y, Maleska M, Martel S, Jeffery MM, Platts-Mills TF, Hess EP, D'Onofrio G, Melnick ER. Computerized Clinical Decision Support System for Emergency Department-Initiated Buprenorphine for Opioid Use Disorder: User-Centered Design. JMIR Hum Factors 2019; 6:e13121. [PMID: 30810531 PMCID: PMC6414819 DOI: 10.2196/13121] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 02/01/2019] [Accepted: 02/09/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Emergency departments (EDs) frequently care for individuals with opioid use disorder (OUD). Buprenorphine (BUP) is an effective treatment option for patients with OUD that can safely be initiated in the ED. At present, BUP is rarely initiated as a part of routine ED care. Clinical decision support (CDS) could accelerate adoption of ED-initiated BUP into routine emergency care. OBJECTIVE This study aimed to design and formatively evaluate a user-centered decision support tool for ED initiation of BUP for patients with OUD. METHODS User-centered design with iterative prototype development was used. Initial observations and interviews identified workflows and information needs. The design team and key stakeholders reviewed prototype designs to ensure accuracy. A total of 5 prototypes were evaluated and iteratively refined based on input from 26 attending and resident physicians. RESULTS Early feedback identified concerns with the initial CDS design: an alert with several screens. The timing of the alert led to quick dismissal without using the tool. User feedback on subsequent iterations informed the development of a flexible tool to support clinicians with varied levels of experience with the intervention by providing both one-click options for direct activation of care pathways and user-activated support for critical decision points. The final design resolved challenging navigation issues through targeted placement, color, and design of the decision support modules and care pathways. In final testing, users expressed that the tool could be easily learned without training and was reasonable for use during routine emergency care. CONCLUSIONS A user-centered design process helped designers to better understand users' needs for a Web-based clinical decision tool to support ED initiation of BUP for OUD. The process identified varying needs across user experience and familiarity with the protocol, leading to a flexible design supporting both direct care pathways and user-initiated decision support.
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Affiliation(s)
- Jessica M Ray
- Yale School of Medicine, New Haven, CT, United States
| | - Osama M Ahmed
- Yale School of Medicine, New Haven, CT, United States
| | | | | | - Shara Martel
- Yale School of Medicine, New Haven, CT, United States
| | | | | | - Erik P Hess
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, United States
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17
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Kane EM, Scheulen JJ, Püttgen A, Martinez D, Levin S, Bush BA, Huffman L, Jacobs MM, Rupani H, T Efron D. Use of Systems Engineering to Design a Hospital Command Center. Jt Comm J Qual Patient Saf 2019; 45:370-379. [PMID: 30638974 DOI: 10.1016/j.jcjq.2018.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 11/30/2018] [Accepted: 11/30/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND In hospitals and health systems across the country, patient flow bottlenecks delay care delivery-emergency department boarding and operating room exit holds are familiar examples. In other industries, such as oil, gas, and air traffic control, command centers proactively manage flow through complex systems. METHODS A systems engineering approach was used to analyze and maximize existing capacity in one health system, which led to the creation of the Judy Reitz Capacity Command Center. This article describes the key elements of this novel health system command center, which include strategic colocation of teams, automated visual displays of real-time data providing a global view, predictive analytics, standard work and rules-based protocols, and a clear chain of command and guiding tenets. Preliminary data are also shared. RESULTS With proactive capacity management, subcycle times decreased and allowed the health system's flagship hospital to increase occupancy from 85% to 92% while decreasing patient delays. CONCLUSION The command center was built with three primary goals-reducing emergency department boarding, eliminating operating room holds, and facilitating transfers in from outside facilities-but the command center infrastructure has the potential to improve hospital operations in many other areas.
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18
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Yusefi AR, Ebrahim Z, Zargar Balaye Jame S, Bastani P. Workload and its Associated Factors among Nurses in Teaching Hospitals of Shiraz
University of Medical Sciences in 2017. JOURNAL OF RESEARCH DEVELOPMENT IN NURSING AND MIDWIFERY 2019. [DOI: 10.29252/jgbfnm.16.1.82] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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19
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Fletcher KA, Potter SM, Telford BN. Stress Outcomes of Four Types of Perceived Interruptions. HUMAN FACTORS 2018; 60:222-235. [PMID: 29131659 DOI: 10.1177/0018720817738845] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Objective We sought to define and measure four types of perceived interruptions and to examine their relationships with stress outcomes. Background Interruptions have been defined and measured in a variety of inconsistent ways. No study has simultaneously examined the subjective experience of all types of interruptions. Method First, we provide a synthesized definition and model of interruptions that aligns interruptions along two qualities: origin and degree of multitasking. Second, we create and validate a self-report measure of these four types of perceived interruptions within two samples (working undergraduate students and working engineers). Last, we correlate this measure with self-reported psychological and physical stress outcomes. Results Our results support the four-factor model of interruptions. Results further support the link between each of the four types of interruptions (intrusions, breaks, distractions, and a specific type of ruminations, discrepancies) and stress outcomes. Specifically, results suggest that distractions explain a unique portion of variance in stress outcomes above and beyond the shared variance explained by intrusions, breaks, and discrepancies. Conclusion The synthesized four-factor model of interruptions is an adequate representation of the overall construct of interruptions. Further, perceived interruptions can be measured and are significantly related to stress outcomes. Application Measuring interruptions by observation can be intrusive and resource intensive. Additionally, some types of interruptions may be internal and therefore unobservable. Our survey measure offers a practical alternative method for practitioners and researchers interested in the outcomes of interruptions, especially stress outcomes.
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20
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Schneider F, Martin J, Hapfelmeier A, Jordan D, Schneider G, Schulz CM. The validity of linear and non-linear heart rate metrics as workload indicators of emergency physicians. PLoS One 2017; 12:e0188635. [PMID: 29190808 PMCID: PMC5708782 DOI: 10.1371/journal.pone.0188635] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 11/11/2017] [Indexed: 11/29/2022] Open
Abstract
Background It has been shown that linear and non-linear heart rate variability (HRV) metrics are suitable to assess workload of anesthetists administering anesthesia. In pre-hospital emergency care, these parameters have not yet been evaluated. We hypothesized that heart rate (HR) and HRV metrics discriminate between differing workload levels of an emergency physician. Methods Electrocardiograms were obtained from 13 emergency physicians. Mean HR, ten linear and seven non-linear HRV metrics were analyzed. For each sortie, four different levels of workload were defined. Mixed-effects models and the area under the receiver operating characteristics curve (AUC) were used to test and quantify the HR and HRV metrics’ ability to discriminate between levels of workload. This was conducted for mean HR and each HRV metric as well as for groups of metrics (time domain vs. frequency domain vs. non-linear metrics). Results The non-linear HRV metric Permutation entropy (PeEn) discriminated best between the time before the alarm and primary patient care (AUC = 0.998, 1st rank of 18 HRV metrics). In contrast, AUC of the mean HR was low (0.558, 17th rank). In the multivariable approach, the non-linear HRV metrics provided a higher AUC (0.998) compared to the frequency domain (0.677) and to the time domain metrics (0.680). Conclusion Non-linear heart rate metrics and, specifically, PeEn provided good validity for the assessment of different levels of a physician’s workload in the setting of pre-hospital emergency care. In contradiction to earlier findings, the physicians’ mean HR was not a valid marker of workload.
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Affiliation(s)
- Frederick Schneider
- Department of Anesthesiology, Klinikum Rechts der Isar, Technische Universität München, München, Germany
- * E-mail:
| | - Jan Martin
- Department of Anesthesiology, Klinikum Rechts der Isar, Technische Universität München, München, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Statistics and Epidemiology, Klinikum Rechts der Isar, Technische Universität München, München, Germany
| | - Denis Jordan
- Hochschule für Architektur, Bau und Geomatik, Institut Vermessung und Geoinformation, Fachhochschule Nordwestschweiz, Muttenz, Switzerland
| | - Gerhard Schneider
- Department of Anesthesiology, Klinikum Rechts der Isar, Technische Universität München, München, Germany
| | - Christian M. Schulz
- Department of Anesthesiology, Klinikum Rechts der Isar, Technische Universität München, München, Germany
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21
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Blocker RC, Heaton HA, Forsyth KL, Hawthorne HJ, El-Sherif N, Bellolio MF, Nestler DM, Hellmich TR, Pasupathy KS, Hallbeck MS. Physician, Interrupted: Workflow Interruptions and Patient Care in the Emergency Department. J Emerg Med 2017; 53:798-804. [PMID: 29079489 DOI: 10.1016/j.jemermed.2017.08.067] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 08/04/2017] [Accepted: 08/11/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND It is unclear how workflow interruptions impact emergency physicians at the point of care. OBJECTIVES Our study aimed to evaluate interruption characteristics experienced by academic emergency physicians. METHODS This prospective, observational study collected interruptions during attending physician shifts. An interruption is defined as any break in performance of a human activity that briefly requires attention. One observer captured interruptions using a validated tablet PC-based tool that time stamped and categorized the data. Data collected included: 1) type, 2) priority of interruption to original task, and 3) physical location of the interruption. A Kruskal-Wallis H test compared interruption priority and duration. A chi-squared analysis examined the priority of interruptions in and outside of the patient rooms. RESULTS A total of 2355 interruptions were identified across 210 clinical hours and 28 shifts (means = 84.1 interruptions per shift, standard deviation = 14.5; means = 11.21 interruptions per hour, standard deviation = 4.45). Physicians experienced face-to-face physician interruptions most frequently (26.0%), followed by face-to-face nurse communication (21.7%), and environment (20.8%). There was a statistically significant difference in interruption duration based on the interruption priority, χ2(2) = 643.98, p < 0.001, where durations increased as priority increased. Whereas medium/normal interruptions accounted for 53.6% of the total interruptions, 53% of the interruptions that occurred in the patient room (n = 162/308) were considered low priority (χ2 [2, n = 2355] = 78.43, p < 0.001). CONCLUSIONS Our study examined interruptions over entire provider shifts and identified patient rooms as high risk for low-priority interruptions. Targeting provider-centered interventions to patient rooms may aid in mitigating the impacts of interruptions on patient safety and enhancing clinical care.
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Affiliation(s)
- Renaldo C Blocker
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Heather A Heaton
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Katherine L Forsyth
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Hunter J Hawthorne
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Nibras El-Sherif
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | | | - David M Nestler
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Kalyan S Pasupathy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - M Susan Hallbeck
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
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22
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Walter SR, Raban MZ, Dunsmuir WTM, Douglas HE, Westbrook JI. Emergency doctors' strategies to manage competing workload demands in an interruptive environment: An observational workflow time study. APPLIED ERGONOMICS 2017; 58:454-460. [PMID: 27633242 DOI: 10.1016/j.apergo.2016.07.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 05/29/2016] [Accepted: 07/30/2016] [Indexed: 06/06/2023]
Abstract
An observational workflow time study was conducted involving doctors in the emergency department (ED) of a large Australian hospital. During 121.7 h across 58 sessions, we observed interruptive events, conceptualised as prompts, and doctors' strategies to handle those prompts (task-switching, multitasking, acknowledgement, deferral and deflection) to assess the role of multiple work system factors influencing doctors' work in the ED. Prompt rates varied vastly between work scenarios, being highest during non-verbal solo tasks. The propensity to use certain strategies also differed with task type, prompt type and location within the department, although task-switching was by far the most frequent. Communicative prompts were important in patient treatment and workload management. Clinicians appear to adjust their communication strategies in response to contextual factors in order to deliver patient care. Risk due to the interruptive nature of ED communication is potentially outweighed by the positive effects of timely information transfer and advice provision.
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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
| | - William T M Dunsmuir
- School of Mathematics and Statistics, Faculty of Science, University of New South Wales, Sydney, Australia
| | - Heather E Douglas
- 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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23
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Weigl M, Schneider A. Associations of work characteristics, employee strain and self-perceived quality of care in Emergency Departments: A cross-sectional study. Int Emerg Nurs 2017; 30:20-24. [DOI: 10.1016/j.ienj.2016.07.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 06/01/2016] [Accepted: 07/15/2016] [Indexed: 10/24/2022]
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24
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Efficiency in the emergency department - A complex relationship between throughput rates and staff perceptions. Int Emerg Nurs 2016; 29:15-20. [PMID: 27524106 DOI: 10.1016/j.ienj.2016.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/16/2016] [Accepted: 07/28/2016] [Indexed: 11/22/2022]
Abstract
INTRODUCTION It is well known that emergency departments (EDs) suffer from crowding and throughput challenges, which make the ED a challenging workplace. However, the interplay between the throughput of patients and how staff experience work is seldom studied. The aim of this study was to investigate whether staff experience of work (efficiency, work-related efforts and rewards, and quantity and quality of work) differs between days with low and high patient throughput rates. METHOD Throughput times were collected from electronic medical records and staff (n=252 individuals, mainly nurses) ratings in daily questionnaires over a total of six weeks. Days were grouped into low and high throughput rate days for the orthopedic, surgical and internal medicine sections, respectively, and staff ratings were compared. RESULTS On days with low throughput rates, employees rated their efficiency, effort, reward and quantity of work significantly higher than on days with high throughput rates. There was no difference in perceived quality of work. CONCLUSIONS There is a complex relationship between ED throughput rates and staff perceptions of efficiency and efforts/rewards with work, suggesting that whereas low throughput may be troublesome from a patient and organizational perspective, working conditions may still be perceived as more favorable.
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Bozzani FM, Arnold M, Colbourn T, Lufesi N, Nambiar B, Masache G, Skordis-Worrall J. Measurement and valuation of health providers' time for the management of childhood pneumonia in rural Malawi: an empirical study. BMC Health Serv Res 2016; 16:314. [PMID: 27464679 PMCID: PMC4964305 DOI: 10.1186/s12913-016-1573-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 07/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Human resources are a major cost driver in childhood pneumonia case management. Introduction of 13-valent pneumococcal conjugate vaccine (PCV-13) in Malawi can lead to savings on staff time and salaries due to reductions in pneumonia cases requiring admission. Reliable estimates of human resource costs are vital for use in economic evaluations of PCV-13 introduction. METHODS Twenty-eight severe and twenty-four very severe pneumonia inpatients under the age of five were tracked from admission to discharge by paediatric ward staff using self-administered timesheets at Mchinji District Hospital between June and August 2012. All activities performed and the time spent on each activity were recorded. A monetary value was assigned to the time by allocating a corresponding percentage of the health workers' salary. All costs are reported in 2012 US$. RESULTS A total of 1,017 entries, grouped according to 22 different activity labels, were recorded during the observation period. On average, 99 min (standard deviation, SD = 46) were spent on each admission: 93 (SD = 38) for severe and 106 (SD = 55) for very severe cases. Approximately 40 % of activities involved monitoring and stabilization, including administering non-drug therapies such as oxygen. A further 35 % of the time was spent on injecting antibiotics. Nurses provided 60 % of the total time spent on pneumonia admissions, clinicians 25 % and support staff 15 %. Human resource costs were approximately US$ 2 per bed-day and, on average, US$ 29.5 per severe pneumonia admission and US$ 37.7 per very severe admission. CONCLUSIONS Self-reporting was successfully used in this context to generate reliable estimates of human resource time and costs of childhood pneumonia treatment. Assuming vaccine efficacy of 41 % and 90 % coverage, PCV-13 introduction in Malawi can save over US$ 2 million per year in staff costs alone.
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Affiliation(s)
- Fiammetta Maria Bozzani
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. .,Institute for Global Health, University College London, London, UK.
| | - Matthias Arnold
- Munich Center of Health Sciences, Ludwig-Maximilians-Universität München, Munich, Germany.,Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany
| | - Timothy Colbourn
- Institute for Global Health, University College London, London, UK
| | | | - Bejoy Nambiar
- Institute for Global Health, University College London, London, UK.,Parent And Child Health Initiative (PACHI), Lilongwe, Malawi
| | - Gibson Masache
- Parent And Child Health Initiative (PACHI), Lilongwe, Malawi
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Kelen G, Peterson S, Pronovost P. In the Name of Patient Safety, Let's Burden the Emergency Department More. Ann Emerg Med 2015; 67:737-740. [PMID: 26707360 DOI: 10.1016/j.annemergmed.2015.11.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Gabor Kelen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Susan Peterson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Peter Pronovost
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Carayon P, Weinger MB, Brown R, Cartmill R, Slagle J, Van Roy KS, Walker JM, Wood KE. How Do Residents Spend Their Time in the Intensive Care Unit? Am J Med Sci 2015; 350:403-8. [PMID: 26171828 PMCID: PMC4626408 DOI: 10.1097/maj.0000000000000520] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To describe the work of residents and the distribution of their time in 6 intensive care units (ICUs) of 2 medical centers (MCs). METHODS A total of 242 hours of observation to capture data on tasks performed by residents in 6 ICUs, including adult, pediatric, medical and surgical units, were conducted. For each observation period, the percentages of total time spent on each task and on the aggregated task categories were calculated. RESULTS Overall, while in the ICUs, residents spent almost half of their time in clinical review and documentation (19%), conversation with team physicians (16%), conversation attendance (6%) and order management (6%). The 2 MCs differed in the time that residents spent on administrative review and documentation (4% in one MC and 15% in the other). The pediatric ICUs were similar in the 2 MCs, whereas the adult ICUs exhibited differences in the time spent on order management and administrative review and documentation. CONCLUSIONS While in the ICUs, residents spent most time performing direct patient care and care coordination activities. The distribution of activities varied across 2 MCs and across ICUs, which highlights the need to consider the local context on residents' work in ICUs.
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Affiliation(s)
- Pascale Carayon
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 1550 Engineering Drive, Madison, WI 53706, Tel: 1-608-263-2520
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 1550 Engineering Drive, Madison, WI 53706, Tel: 1-608-263-2520
| | - Matthew B. Weinger
- Center for Research & Innovation in Systems Safety, Department of Anesthesiology, Vanderbilt University School of Medicine, 732 Medical Arts Building, 1211 21 Avenue South, Nashville, TN 37212, Tel: 1-615-936-5597
| | - Roger Brown
- School of Nursing, University of Wisconsin-Madison, 701 Highland Avenue, Madison, WI 53705, Tel: 1-608-263-5200
| | - Randi Cartmill
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 1550 Engineering Drive, Madison, WI 53706, Tel: 1-608-263-2520
| | - Jason Slagle
- Center for Research & Innovation in Systems Safety, Department of Anesthesiology, Vanderbilt University School of Medicine, 732 Medical Arts Building, 1211 21 Avenue South, Nashville, TN 37212, Tel: 1-615-936-5597
| | - Kara Schultz Van Roy
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 1550 Engineering Drive, Madison, WI 53706, Tel: 1-608-263-2520
| | - James M. Walker
- Siemens Healthcare IT, 415 15 Street, New Cumberland, PA 17070, Tel: 1-610-209-2894
| | - Kenneth E. Wood
- Geisinger Health System, 100 N. Academy Ave., New Cumberland, PA 17822, Tel: 1-570-271-6750
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Weigl M, Müller A, Holland S, Wedel S, Woloshynowych M. Work conditions, mental workload and patient care quality: a multisource study in the emergency department. BMJ Qual Saf 2015; 25:499-508. [DOI: 10.1136/bmjqs-2014-003744] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 08/20/2015] [Indexed: 11/04/2022]
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Redd TK, Read-Brown S, Choi D, Yackel TR, Tu DC, Chiang MF. Electronic health record impact on productivity and efficiency in an academic pediatric ophthalmology practice. J AAPOS 2014; 18:584-9. [PMID: 25456030 PMCID: PMC4267903 DOI: 10.1016/j.jaapos.2014.08.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 06/24/2014] [Accepted: 08/25/2014] [Indexed: 11/15/2022]
Abstract
PURPOSE To measure the effect of electronic health record (EHR) implementation on productivity and efficiency in the pediatric ophthalmology division at an academic medical center. METHODS Four established providers were selected from the pediatric ophthalmology division at the Oregon Health & Science University Casey Eye Institute. Clinical volume was compared before and after EHR implementation for each provider. Time elapsed from chart open to completion (OTC time) and the proportion of charts completed during business hours were monitored for 3 years following implementation. RESULTS Overall there was an 11% decrease in clinical volume following EHR implementation, which was not statistically significant (P = 0.18). The mean OTC time ranged from 5.5 to 28.3 hours among providers in this study, and trends over time were variable among the four providers. Forty-four percent of all charts were closed outside normal business hours (30% on weekdays, 14% on weekends). CONCLUSIONS EHR implementation was associated with a negative impact on productivity and efficiency in our pediatric ophthalmology division.
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Affiliation(s)
- Travis K Redd
- Department of Ophthalmology, Portland, Oregon; Department of Public Health & Preventive Medicine, Portland, Oregon
| | | | - Dongseok Choi
- Department of Ophthalmology, Portland, Oregon; Department of Public Health & Preventive Medicine, Portland, Oregon; Community Dentistry, Oregon Health & Science University, Portland, Oregon
| | - Thomas R Yackel
- Department of Medical Informatics & Clinical Epidemiology, Portland, Oregon
| | - Daniel C Tu
- Department of Ophthalmology, Portland, Oregon; Operative Care Division, Portland Veterans Affairs Medical Center, Portland, Oregon
| | - Michael F Chiang
- Department of Ophthalmology, Portland, Oregon; Department of Medical Informatics & Clinical Epidemiology, Portland, Oregon.
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Nable JV, Greenwood JC, Abraham MK, Bond MC, Winters ME. Implementation of a team-based physician staffing model at an academic emergency department. West J Emerg Med 2014; 15:682-6. [PMID: 25247043 PMCID: PMC4162729 DOI: 10.5811/westjem.2014.5.20700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Accepted: 05/05/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction There is scant literature regarding the optimal resident physician staffing model of academic emergency departments (ED) that maximizes learning opportunities. A department of emergency medicine at a large inner-city academic hospital initiated a team-based staffing model. Its pre-interventional staffing model consisted of residents and attending physicians being separately assigned patients, resulting in residents working with two different faculty providers in the same shift. This study aimed to determine if the post-interventional team-based system, in which residents were paired with a single attending on each shift, would result in improved residents’ learning and clinical experiences as manifested by resident evaluations and the number of patients seen. Methods This retrospective before-and-after study at an academic ED with an annual volume of 52,000 patients examined the mean differences in five-point Likert-scale evaluations completed by residents assessing their ED rotation experiences in both the original and team-based staffing models. The residents were queried on their perceptions of feeling part of the team, decision-making autonomy, clinical experience, amount of supervision, quality of teaching, and overall rotational experience. We also analyzed the number of patients seen per hour by residents. Paired sample t-tests were performed. Residents who were in the program in the year preceding and proceeding the intervention were eligible for inclusion. Results 34 of 38 eligible residents were included (4 excluded for lack of evaluations in either the pre- or post-intervention period). There was a statistically significant improvement in resident perception of the quality and amount of teaching, 4.03 to 4.27 (mean difference=0.24, p=0.03). There were non-statistically significant trends toward improved mean scores for all other queries. Residents also saw more patients following the initiation of the team-based model, 1.24 to 1.56 patients per hour (mean difference=0.32, p=0.0005). Conclusion Adopting a team-based physician staffing model is associated with improved resident perceptions of quality and amount of teaching. Residents also experience a greater number of patient evaluations in a team-based model.
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Affiliation(s)
- Jose V Nable
- University of Maryland Baltimore County, Department of Emergency Health Services, Baltimore, Maryland ; University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - John C Greenwood
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Michael K Abraham
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Michael C Bond
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Michael E Winters
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
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Weigl M, Müller A, Angerer P, Hoffmann F. Workflow interruptions and mental workload in hospital pediatricians: an observational study. BMC Health Serv Res 2014; 14:433. [PMID: 25253542 PMCID: PMC4263126 DOI: 10.1186/1472-6963-14-433] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 09/11/2014] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Matthias Weigl
- Institute and Outpatient Clinic for Occupational, Social, and Environmental Medicine, Ludwig-Maximilians-University, Munich, Germany.
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The impact of intra-operative interruptions on surgeons' perceived workload: an observational study in elective general and orthopedic surgery. Surg Endosc 2014; 29:145-53. [PMID: 24986016 DOI: 10.1007/s00464-014-3668-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 05/31/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND AIM Surgeons' intra-operative workload is critical for effective and safe surgical performance. Detrimental conditions in the operating room (OR) environment may add to perceived workload and jeopardize surgical performance and outcomes. This study aims to evaluate the impact of different intra-operative workflow interruptions on surgeons' capacity to manage their workload safely and efficiently. METHODS This was an observational study of intra-operative interruptions and self-rated workload in two surgical specialties (general, orthopedic/trauma surgery). Intra-operative interruptions were assessed via expert observation using a well-validated observation tool. Surgeons, nurses, and anesthesiologists assessed their intra-operative workload directly after case completion based on three items of the validated Surgery Task Load Index (mental demand, situational stress, distraction). RESULTS A total of 56 elective cases (35 open, 21 laparoscopic) with 94 workload ratings were included. Mean intra-operative duration was 1 h 37 min. Intra-operative interruptions were on average observed 9.78 times per hour. People who entered/exited the OR (30.6 %) as well as telephone-/beeper-related disruptions (23.6 %) occurred most often. Equipment and OR environment-related interruptions were associated with highest interference with team functioning particularly in laparoscopic procedures. After identifying task and procedural influences, partial correlational analyses revealed that case-irrelevant communications were negatively associated with surgeons' mental fatigue and situational stress, whereas surgeons' reported distraction was increased by case-irrelevant communication and procedural disruptions. OR nurses' and anesthesiologists' perceived workload was also related to intra-operative interruption events. CONCLUSIONS Our study documents the unique contribution of different interruptions on surgeons' workload; whereas case-irrelevant communications may be beneficial for mental fatigue and stress in routine cases, procedural interruptions and case-irrelevant communication may contribute to surgeons' mental focus deteriorating. Well-designed OR environments, surgical leadership, and awareness can help to control unnecessary interruptions for effective and safe surgical care.
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Laurie-Rose C, Frey M, Ennis A, Zamary A. Measuring perceived mental workload in children. AMERICAN JOURNAL OF PSYCHOLOGY 2014; 127:107-25. [PMID: 24720100 DOI: 10.5406/amerjpsyc.127.1.0107] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Little is known about the mental workload, or psychological costs, associated with information processing tasks in children. We adapted the highly regarded NASA Task Load Index (NASA-TLX) multidimensional workload scale (Hart & Staveland, 1988) to test its efficacy for use with elementary school children. We developed 2 types of tasks, each with 2 levels of demand, to draw differentially on resources from the separate subscales of workload. In Experiment 1, our participants were both typical and school-labeled gifted children recruited from 4th and 5th grades. Results revealed that task type elicited different workload profiles, and task demand directly affected the children's experience of workload. In general, gifted children experienced less workload than typical children. Objective response time and accuracy measures provide evidence for the criterion validity of the workload ratings. In Experiment 2, we applied the same method with 1st- and 2nd-grade children. Findings from Experiment 2 paralleled those of Experiment 1 and support the use of NASA-TLX with even the youngest elementary school children. These findings contribute to the fledgling field of educational ergonomics and attest to the innovative application of workload research. Such research may optimize instructional techniques and identify children at risk for experiencing overload.
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Entropy: A Conceptual Approach to Measuring Situation-level Workload Within Emergency Care and its Relationship to Emergency Department Crowding. J Emerg Med 2014; 46:551-9. [DOI: 10.1016/j.jemermed.2013.08.113] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Revised: 08/02/2013] [Accepted: 08/20/2013] [Indexed: 11/22/2022]
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The Evolving Role of the Radiologist: The Vancouver Workload Utilization Evaluation Study. J Am Coll Radiol 2013; 10:764-9. [DOI: 10.1016/j.jacr.2013.04.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 04/02/2013] [Indexed: 11/22/2022]
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Abstract
Extensive research has examined the effects of workload on individual performance. Despite the increasing prevalence of teams addressing complex tasks with high workload, less attention has focused on workload distributions beyond the individual to the team level, likely due to the inherent complexity of defining and measuring team workload. By drawing upon previous work by Funke et al. (2012), the authors synthesize existing literature detailing individual/team performance and workload theory and empirical findings across research domains. Based on this synthesis, a multilevel, theoretically derived framework of team workload, rooted in the science of individual/team performance in complex, dynamic environments is proposed.
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Affiliation(s)
- Wendy L. Bedwell
- University of South Florida, USA; University of Central Florida, USA
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Relationships of multitasking, physicians' strain, and performance: an observational study in ward physicians. J Patient Saf 2013; 9:18-23. [PMID: 23007246 DOI: 10.1097/pts.0b013e31826b7b87] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Simultaneous task performance ("multitasking") is common in hospital physicians' work and is implicated as a major determinant for enhanced strain and detrimental performance. OBJECTIVE The aim was to determine the impact of multitasking by hospital physicians on their self reported strain and performance. METHOD A prospective observational time-and-motion study in a Community Hospital was conducted. Twenty-seven hospital physicians (surgical and internal specialties) were observed in 40 full-shift observations. Observed physicians reported twice on their self-monitored strain and performance during the observation time. Associations of observed multitasking events and subsequent strain and performance appraisals were calculated. RESULTS About 21% of the working time physicians were engaged in simultaneous activities. The average time spent in multitasking activities correlated significantly with subsequently reported strain (r = 0.27, P = 0.018). The number of instances of multitasking activities correlated with self-monitored performance to a marginally significant level (r = 0.19, P = 0.098). CONCLUSION Physicians who engage in multitasking activities tend to self-report better performance but at the cost of enhanced psychophysical strain. Hence, physicians do not perceive their own multitasking activities as a source for deficient performance, for example, medical errors. Readjustment of workload, improved organization of work for hospital physicians, and training programs to improve physicians' skills in dealing with multiple clinical demands, prioritization, and efficient task allocation may be useful avenues to explore to reduce the potentially negative impact of simultaneous task performance in clinical settings.
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Parsons SE, Carter EA, Waterhouse LJ, Sarcevic A, O'Connell KJ, Burd RS. Assessment of workload during pediatric trauma resuscitation. J Trauma Acute Care Surg 2013; 73:1267-72. [PMID: 23117383 DOI: 10.1097/ta.0b013e318265d15a] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Trauma resuscitations are high-pressure, time-critical events during which health care providers form ad hoc teams to rapidly assess and treat injured patients. Trauma team members experience varying levels of workload during resuscitations resulting from the objective demands of their role-specific tasks, the circumstances surrounding the event, and their individual previous experiences. The goal of this study was to determine factors influencing workload experienced by trauma team members during pediatric trauma resuscitations. METHODS Workload was measured using the National Aeronautics and Space Administration Task Load Index (TLX). TLX surveys were administered to four trauma team roles: charge nurse, senior surgical resident (surgical coordinator), emergency medicine physician, and junior surgical resident or nurse practitioner (bedside clinician). A total of 217 surveys were completed. Univariate and multivariate statistical techniques were used to examine the relationship between workload and patient and clinical factors. RESULTS Bedside clinicians reported the highest total workload score (208.7), followed by emergency medicine physicians (156.3), surgical coordinators (144.1), and charge nurses (129.1). Workload was higher during higher-level activations (235.3), for events involving intubated patients (249.0), and for patients with an Injury Severity Score greater than 15 (230.4) (p, 0.001 for all). When controlling for potential confounders using multiple linear regression, workload was increased during higher level activations (79.0 points higher, p = 0.01) and events without previous notification (38.9 points higher, p = 0.03). Workload also remained significantly higher for the bedside clinician compared with the other three roles (p ≤ 0.005 for all). CONCLUSION Workload during pediatric trauma resuscitations differed by team role and was increased for higher-level activations and events without previous notification. This study demonstrates the validity of the TLX as a tool to measure workload in trauma resuscitation. LEVEL OF EVIDENCE Prognostic study, level II.
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Affiliation(s)
- Samantha E Parsons
- Division of Trauma and Burns, Children's National Medical Center, Washington, District of Columbia 20010, USA
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Person J, Spiva L, Hart P. The culture of an emergency department: an ethnographic study. Int Emerg Nurs 2012; 21:222-7. [PMID: 23228617 DOI: 10.1016/j.ienj.2012.10.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 10/14/2012] [Accepted: 10/18/2012] [Indexed: 11/29/2022]
Abstract
In an environment of change and social interaction, hospital emergency departments create a unique sub-culture within healthcare. Patient-centered care, stressful situations, social gaps within the department, pressure to perform, teamwork, and maintaining a work-life balance were examined as influences that have developed this culture into its current state. The study aim was to examine the culture in an emergency department. The sample consisted of 34 employees working in an emergency department, level II trauma center, located in the Southeastern United States. An ethnographic approach was used to gather data from the perspective of the cultural insider. Data revealed identification of four categories that included cognitive, environmental, linguistic, and social attributes that described the culture. Promoting a culture that values the staff is essential in building an environment that fosters the satisfaction and retention of staff. Findings suggest that efforts be directed at improving workflow and processes. Development and training opportunities are needed to improve relationships to promote safer, more efficient patient care. Removing barriers and improving processes will impact patient safety, efficiency, and cost-effectiveness. Findings show that culture is influenced and created by multiple elements.
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Affiliation(s)
- John Person
- WellStar Kennestone Hospital, 677 Church Street, Marietta, GA 30060, United States
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Levin S, Sauer L, Kelen G, Kirsch T, Pham J, Desai S, France D. Situation awareness in emergency medicine. ACTA ACUST UNITED AC 2012. [DOI: 10.1080/19488300.2012.684739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Byrne A. Measurement of mental workload in clinical medicine: a review study. Anesth Pain Med 2011; 1:90-4. [PMID: 25729663 PMCID: PMC4335734 DOI: 10.5812/kowsar.22287523.2045] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 08/10/2011] [Accepted: 08/15/2011] [Indexed: 11/16/2022] Open
Abstract
Background: Measures of mental workload are now commonly used in industries to identify sources of error and to improve performance. Objectives: This study aimed to review the evidence for the use of this technique within medicine. Patients and Methods: We used search engines and the internet to identify experimental studies that included a measure of mental workload in medical practitioners or trainees/students. Studies that aimed to measure mental “stress” as a disorder, or “productivity” were excluded. Each abstract and then the full paper were appraised prior to inclusion. Results: Thirty-three studies were identified that matched the inclusion criteria. Although these covered a variety of settings, common methods were identifiable. The results support the concept of mental workload measurement as an important factor in medical performance. Conclusions: The limited number of studies and the variety of definitions and measurement techniques used in these studies, make direct comparisons difficult. However, the utility of this methodology in medical education appears to have been established, and guidelines for further research methods are proposed.
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Affiliation(s)
- Aidan Byrne
- Clinical Skills and Simulation, School of Medicine, Cardiff University, Cardiff, UK
- Corresponding author: Aidan Byrne, Department of Medical Education, Cardiff University, Heath Park, P O. Box: CF14 4XN, Cardiff, UK. Tel: +44-1792602618, E-mail:
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Abstract
BACKGROUND The level of work intensity associated with patient encounters has implications for quality of care, patient safety, practice management, and reimbursement. The utility of available instruments for clinical work intensity assessment is unknown. OBJECTIVE We assessed, in the clinical setting, the performance of existing measures of work intensity that are valid for nonclinical contexts. RESEARCH DESIGN A cross-sectional, multimeasure design involving work intensity assessments for the last patient encounter and for an entire half-day clinic session. SUBJECTS A convenience sample of 14 providers from the following 4 specialties: family medicine, general internal medicine, neurology, and surgery. MEASURES Perceived clinical work intensity was measured by the following 3 instruments: National Aeronautic and Space Administration-Task Load Index, Subjective Workload Assessment Technique, and Multiple Resources Questionnaire; stress was measured by the Dundee Stress State Questionnaire. Convergent validity was assessed by correlation among the instruments. RESULTS For the last patient encounter, there was a moderate to high correlation between the work intensity instruments' scores (Pearson's r ranged from 0.41 to 0.73) and low to moderate correlation with the distress subscale of the Dundee Stress State Questionnaire (Pearson's r ranged from -0.11 to 0.46), reflecting their stress dimension. Provider personality was associated with reported levels of work intensity and stress. Similar results were obtained when the entire clinic session was the unit of reference. CONCLUSION Existing measures of work intensity and stress appear to be valid for use in the clinical setting to generate evidence on perceived intensity and stress experienced by providers in the performance of medical services.
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Access versus acculturation: identifying modifiable factors to promote cancer screening among Asian American women. Med Care 2010; 49:52-8. [PMID: 20966779 DOI: 10.1097/mlr.0b013e3181f53542] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Asian Americans (AA) have the lowest rates of cancer screening of all ethnic groups. Reasons for these low rates of screening frequently include low acculturation levels. However, screening rates remain low for most AA populations despite differences in acculturation levels, suggesting presence of other important modifiers such as access barriers. OBJECTIVES To compare the relative impact of access versus acculturation on breast and cervical cancer screening for AA subgroups. RESEARCH DESIGN Multiple regressions models, controlling for sociodemographics, were developed for each AA subgroup. SUBJECTS Women ages 18 and older from the 2003 California Health Interview Survey were included in this study. We included women with Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese origins. MEASURES The dependent variables included clinical breast examination in the past year, mammogram in the past 2 years, and Pap test in the past 3 years. Independent variables included AA subgroup, access indicators, acculturation indicators, and other sociodemographics. RESULTS Access explained more variation that acculturation alone in cancer screening for most AA women. The exceptions were in mammograms for Japanese, Koreans and South Asians and Pap test among Japanese. No insurance reduced the likelihood of clinical breast examination for immigrant Chinese and Filipinos, and no usual source of care reduced likelihood of Pap test for Japanese and South Asians compared with US born. CONCLUSIONS Access indicators represent the ability to navigate the US health care system but have a differential impact on AA groups. These differences should be integrated into interventions designed to improve cancer screening rates.
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Higher Mental Workload is Associated With Poorer Laparoscopic Performance as Measured by the NASA-TLX Tool. Simul Healthc 2010; 5:267-71. [DOI: 10.1097/sih.0b013e3181e3f329] [Citation(s) in RCA: 211] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Caldwell B, Garrett S, Boustany K. Healthcare Team Performance in Time Critical Environments: Coordinating Events, Foraging, and System Processes. JOURNAL OF HEALTHCARE ENGINEERING 2010. [DOI: 10.1260/2040-2295.1.2.255] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Hu YC, Chen JC, Chiu HT, Shen HC, Chang WY. Nurses’ perception of nursing workforce and its impact on the managerial outcomes in emergency departments. J Clin Nurs 2010; 19:1645-53. [DOI: 10.1111/j.1365-2702.2009.02999.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Holden RJ, Patel NR, Scanlon MC, Shalaby TM, Arnold JM, Karsh BT. Effects of mental demands during dispensing on perceived medication safety and employee well-being: a study of workload in pediatric hospital pharmacies. Res Social Adm Pharm 2010; 6:293-306. [PMID: 21111387 DOI: 10.1016/j.sapharm.2009.10.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Revised: 10/23/2009] [Accepted: 10/25/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pharmacy workload is a modifiable work system factor believed to affect both medication safety outcomes and employee outcomes, such as job satisfaction. OBJECTIVES This study sought to measure the effect of workload on safety and employee outcomes in 2 pediatric hospitals and to do so using a novel approach to pharmacy workload measurement. METHODS Rather than measuring prescription volume or other similar indicators, this study measured the type and intensity of mental demands experienced during the medication dispensing tasks. The effects of external (interruptions, divided attention, and rushing) and internal (concentration and effort) task demands on perceived medication error likelihood, adverse drug event likelihood, job dissatisfaction, and burnout were statistically estimated using multiple linear and logistic regression. RESULTS Pharmacists and pharmacy technicians reported high levels of external and internal mental demands during dispensing. The study supported the hypothesis that external demands (interruptions, divided attention, and rushing) negatively impacted medication safety and employee well-being outcomes. However, as hypothesized, increasing levels of internal demands (concentration and effort) were not associated with greater perceived likelihood of error, adverse drug events, or burnout and even had a positive effect on job satisfaction. CONCLUSIONS Replicating a prior study in nursing, this study shows that new conceptualizations and measures of workload can generate important new findings about both detrimental and beneficial effects of workload on patient safety and employee well-being. This study discusses what those findings imply for policy, management, and design concerning automation, cognition, and staffing.
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Affiliation(s)
- Richard J Holden
- School of Medicine and Public Health, University of Wisconsin-Madison, 1550 Engineering Drive, Madison, WI 53706, USA.
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