Study tracks effects of interruptions on Emergency Physicians

[willow18]

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Came across this on CNN.

CNN -- Interruptions in the emergency room may exact an unhealthy toll on patient care, a group of Australian researchers reported Thursday.
The researchers, from the University of Sydney and the University of New South Wales, found that interruptions led emergency department doctors to spend less time on the tasks they were working on and, in nearly a fifth of cases, to give up on the task altogether.

The researchers carried out a time-and-motion study in the emergency department of a 400-bed teaching hospital, observing 40 doctors for more than 210 hours.

They found that each doctor was typically interrupted 6.6 times per hour; 11 percent of all tasks were interrupted, 3.3 percent of them more than once. They calculated time on task and found that physicians spent less time on interrupted tasks than on uninterrupted tasks. In addition, doctors were multitasking 12.8 percent of the time.

Doctors did not return to 18.5 percent of the interrupted tasks, according to the study, which was published in the journal Quality and Safety in Health Care.
http://www.cnn.com/2010/HEALTH/05/12/doctors.interrupted/index.html?hpt=C1

Here's the link to the study (only abstract is free): http://qshc.bmj.com/content/early/2010/04/20/qshc.2009.039255.short?q=w_qshc_ahead_tab

Raises an interesting issue. Are these "interruptions" inherent in any busy ED or can rules be implemented (don't interrupt EP while obviously "completing a task", etc unless urgent).

Many recent studies have shown that multitasking, even among people who considered themselves expert multitaskers, leads to much poorer outcomes than single tasking, if you will; makes sense, but puts to bed the whole "I'm a good multitasker".

The only other studies I could find that focused specifically on interruptions in the ED (having had to weed through plenty of results on a certain other interruptus 🙄):

• http://www.ncbi.nlm.nih.gov/pubmed/17569576 - just observed quantity and quality of interruptions
  
• http://www.ncbi.nlm.nih.gov/pubmed/11073472 - as above, more detail but didn't follow outcomes, i.e. did the task-break result in an uncompleted task.

So, any thoughts/suggestions from practitioners?

 

[xaelia]

The first work I am aware of observing errors in task resumption following primary task interruption came out of U.S. Naval researchers - another career, I presume, where mistakes kill people. No question that interruptions increase time to task completion as well as the likelihood of errors.

As for the Emergency Department, now you have to come up with a sustainable intervention that you believe is going to change outcomes - as well as figure out what the outcome measure would be. Is it total time to disposition? Reduction in patient safety net complaints? Change in Press-Ganey score? % of STEMI door-to-needle success, average to antibiotics in sepsis, etc.? And I'm not sure what intervention might be successful in the Emergency Department. A simple one might simply be before/after elimination of overhead paging in the Department. Not only is the overhead paging from the general hospital (housekeeping for the rest of the hospital gets paged overhead in our department!), the majority of overhead paging in the department is irrelevant to any one individual practicioner. With the right outcome measure, I have no doubt you could find improvement after elimination of these sorts of distractions.

 

[Arcan57]

The very nature of our specialty is constant interruptions. I am aware of the data that everyone does true multi-tasking very poorly. And there are interruptions that definitely do not add to patient care that should be eliminated. What I would hate to do, is see an EM resident use this as an excuse not to work on becoming more efficient with cognitive tasks such as returning to or reprioritizing the interrupted task. The ability to accurately and efficiently queue critical tasks is one of the hallmarks of our profession.

 

[quinsy]

Xaelia, I believe that because the research has been done purportedly showing that interruptions result in poorer care, you would not need to have any outcome measure aside from decreased interruptions. The assumption would be that decreased interruptions would ameliorate the identified problem.

I think that something as simple as having a brief talk to the nurses in one of their meetings, and the secretaries, would produce a measurable result. Of course, this is one of those things that you need to periodically remind people of when they start to forget, just like many other quality improvement issues. You simply tell the nurses and secretaries that interrupted care is poorer care, and thus we need to minimize interruptions, and suggest specific actions and scenarios under which the interruptions could be avoided.

How many times have we seen nurses coming and interrupting sign-out for some irrelevant detail, or the secretary sending in some phone call from whoever to transfer a stubbed toe to the trauma center. It should be stressed that phone calls should wait until after sign-out and nurses should only interrupt sign-out if a patient is decompensating or otherwise needs urgently to be seen. These are specific examples directed towards sign-out, as we all know, sign out is a problem area for screwing up patient care during which it might be easier to target decreasing interruptions.

Second thought: at one of the community EDs where I work, the EMR allows any user to send a message to any other user, sort of a like an intra-net e-mail. Thus, nurses and others are able to send non-urgent messages/reminders to the physicians which can be viewed in between tasks, rather than being discussed while trying to accomplish something else. This gives the physician more freedom to prioritize which tasks are most important at any given time. Just some thoughts.

 

[willow18]

The very nature of our specialty is constant interruptions. I am aware of the data that everyone does true multi-tasking very poorly. And there are interruptions that definitely do not add to patient care that should be eliminated. What I would hate to do, is see an EM resident use this as an excuse not to work on becoming more efficient with cognitive tasks such as returning to or reprioritizing the interrupted task. The ability to accurately and efficiently queue critical tasks is one of the hallmarks of our profession.

Any tips for queuing tasks? Do you keep a little notepad or just take mental notes? Keep reviewing the "white board" every so often?

 

[xaelia]

Xaelia, I believe that because the research has been done purportedly showing that interruptions result in poorer care, you would not need to have any outcome measure aside from decreased interruptions. The assumption would be that decreased interruptions would ameliorate the identified problem.

I think that something as simple as having a brief talk to the nurses in one of their meetings, and the secretaries, would produce a measurable result.

The number of nonsensical innovations that come from our nursing staff meetings that generate more interruptions, documentation hassle, and decreased morale is immeasurable. "Common sense" reforms based on theoretical harms are far less well received by administrators who prefer proven risk amelioration strategies or documented cost savings.

 

[Arcan57]

Any tips for queuing tasks? Do you keep a little notepad or just take mental notes? Keep reviewing the "white board" every so often?

I use a combination of those approaches. At the start of every shift I'll fold a piece of paper into quarters. Each quarter fits 8 patient stickers. When a patient is dispositioned, the sticker gets an x through it. For the first quarter mental notes are usually sufficient. At 12 or so patients, I usually go back and review who from the first page is still active. They will get a checkbox indicating why they are still active (CT, 2nd POC markers, etc). I'll also do that again for the second quarter when I go to the third quarter. If I'm working with a midlevel on my side, I'll run the tracking board every hour or so to make sure work-ups are progressing. The later into my shift or the more stressed I am, the more notes I'll make.

 

[NYRN]

I use a combination of those approaches. At the start of every shift I'll fold a piece of paper into quarters. Each quarter fits 8 patient stickers. When a patient is dispositioned, the sticker gets an x through it. For the first quarter mental notes are usually sufficient. At 12 or so patients, I usually go back and review who from the first page is still active. They will get a checkbox indicating why they are still active (CT, 2nd POC markers, etc). I'll also do that again for the second quarter when I go to the third quarter. If I'm working with a midlevel on my side, I'll run the tracking board every hour or so to make sure work-ups are progressing. The later into my shift or the more stressed I am, the more notes I'll make.

I do the same thing. Write the names down and the sticker in each box along with what needs to be done/is done, and patient info such as CC, allergies, hx. There is no feeling like being able to put an X through that box 🙂

To the OP, there is no way you can remember everything about the patient or everything that needs to be done. You will come up with your own system but this is a good way to start.