Interruptions in emergency department work: an observational and interview study

Provider interruptions and patient perceptions of care: an observational study in the emergency department

BACKGROUND

Interruptions are endemic in healthcare work environments. Yet, they can have positive effects in some instances and negative in others, with their net effect on quality of care still poorly understood. We aimed to distinguish beneficial and detrimental forms of interruptions of emergency department (ED) providers using patients' perceptions of ED care as a quality measure.

METHODS

An observational design was established. The study setting was an interdisciplinary ED of an academic tertiary referral hospital. Frequencies of interruption sources and contents were identified in systematic expert observations of ED physicians and nurses. Concurrently, patients rated overall quality of care, ED organisation, patient information and waiting times using a standardised survey. Associations were assessed with hierarchical linear models controlling for daily ED workload. Regression results were adjusted for multiple testing. Additionally, analyses were computed for ED physicians and nurses, separately.

RESULTS

On 40 days, 160 expert observation sessions were conducted. 1418 patients were surveyed. Frequent interruptions initiated by patients were associated with higher overall quality of care and ED organisation. Interruptions relating to coordination activities were associated with improved ratings of ED waiting times. However, interruptions containing information on previous cases were associated with inferior ratings of ED organisation. Specifically for nurses, overall interruptions were associated with superior patient reports of waiting time.

CONCLUSIONS

Provider interruptions were differentially associated with patient perceptions of care. Whereas coordination-related and patient-initiated interruptions were beneficial to patient-perceived efficiency of ED operations, interruptions due to case-irrelevant communication were related to inferior patient ratings of ED organisation. The design of resilient healthcare systems requires a thorough consideration of beneficial and harmful effects of interruptions on providers' workflows and patient safety.

Understanding Emergency Medicine Physicians Multitasking Behaviors Around Interruptions

BACKGROUND

Interruptions can adversely impact human performance, particularly in fast-paced and high-risk environments such as the emergency department (ED). Understanding physician behaviors before, during, and after interruptions is important to the design and promotion of safe and effective workflow solutions. However, traditional human factors-based interruption models do not accurately reflect the complexities of real-world environments like the ED and may not capture multiple interruptions and multitasking.

METHODS

We present a more comprehensive framework for understanding interruptions that is composed of three phases, each with multiple levels: interruption start transition, interruption engagement, and interruption end transition. This three-phase framework is not constrained to discrete task transitions, providing a robust method to categorize multitasking behaviors around interruptions. We apply this framework in categorizing 457 interruption episodes.

RESULTS

A total of 457 interruption episodes were captured during 36 hours of observation. The interrupted task was immediately suspended 348 (76.1%) times. Participants engaged in new self-initiated tasks during the interrupting task 164 (35.9%) times and did not directly resume the interrupted task in 284 (62.1%) interruption episodes.

CONCLUSION

Using this framework provides a more detailed description of physician behaviors in complex environments. Understanding the different types of interruption and resumption patterns, which may have a different impact on performance, can support the design of interruption mitigation strategies.

Distractions and interruptions in a surgical room: perception of nursing staff

Abstract Objective: To understand the perception of nursing staff about intraoperative distractions and interruptions. Methods: An exploratory qualitative study was performed with 16 nursing professionals of a surgical center in Minas Gerais. The data were collected through a semi-structured interview and thematic content analysis was performed. Results: When reflecting on the occurrence of distractions and interruptions of intraoperative activities, nursing professionals define, identify and value events in a heterogeneous way, but believe that distractions and interruptions negatively affect both the quality of the work environment and the safety of care provided to the surgical patient. Factors contributing to the occurrence of distractions and interruptions are related to aspects inside the operating room such as equipment failure and use of cell phones and to external factors such as verbal messages given at the operating room door. Incidents have been reported due to distractions, but there are no established actions to minimize these events. Conclusion: This study indicates the importance of implementing strategies that minimize the occurrence of distractions and interruptions of intraoperative activities in order to plan surgical care better, and prevent and mitigate harm to patients.

Pediatric Medication Safety in the Emergency Department

Pediatric patients cared for in emergency departments (EDs) are at high risk of medication errors for a variety of reasons. A multidisciplinary panel was convened by the Emergency Medical Services for Children program and the American Academy of Pediatrics Committee on Pediatric Emergency Medicine to initiate a discussion on medication safety in the ED. Top opportunities identified to improve medication safety include using kilogram-only weight-based dosing, optimizing computerized physician order entry by using clinical decision support, developing a standard formulary for pediatric patients while limiting variability of medication concentrations, using pharmacist support within EDs, enhancing training of medical professionals, systematizing the dispensing and administration of medications within the ED, and addressing challenges for home medication administration before discharge.

Workflow interruptions and stress atwork: a mixed-methods study among physicians and nurses of a multidisciplinary emergency department

OBJECTIVES

Dealing with multiple workflow interruptions is a major challenge in emergency department (ED) work. This study aimed to establish a taxonomy of workflow interruptions that takes into account the content and purpose of interruptive communication. It further aimed to identify associations of workflow interruptions with ED professionals' work stress.

DESIGN

Combined data from expert observation sessions and concomitant self-evaluations of ED providers.

SETTING

ED of an academic community hospital in Germany.

PARTICIPANTS

Multidisciplinary sample of ED physicians and nurses. 77 matched observation sessions of interruptions and self-evaluations of work stress were obtained on 20 randomly selected days.

OUTCOME MEASURES

ED professionals' stress evaluations were based on standardised measures. ED workload data on patient load, patient acuity and staffing were included as control variables in regression analyses.

RESULTS

Overall mean rate was 7.51 interruptions/hour. Interruptions were most frequently caused by ED colleagues of another profession (27.1%; mean interruptions/hour rate: 2.04), by ED colleagues of the same profession (24.1%; 1.81) and by telephone/beeper (21%; 1.57). Concerning the contents of interruption events, interruptions most frequently occurred referring to a parallel case under care (30.3%, 2.07), concerning the current case (19.1%; 1.28), or related to coordination activities (18.2%, 1.24). Regression analyses revealed that interruptive communication related to parallel cases significantly increased ED providers' stress levels (β=0.24, P=0.03). This association remained significant after controlling for ED workload.

DISCUSSION

Interruptions that refer to parallel cases under care were associated with increased stress among ED physicians and nurses. Our approach to distinguish between sources and contents of interruptions contributes to an improved understanding of potential benefits and risks of workflow interruptions in ED work environments. Despite some limitations, our findings add to future research on the implications of interruptions for effective and safe patient care and work in complex and dynamic care environments.

Work Interruption Experienced by Nurses during Medication Administration Process and Associated Factors, Northwest Ethiopia

BACKGROUND

During medication administration process, including preparation, administration, and documentation, there is high proportion of work interruption that results in medication administration errors that consequently affect the safety of patients. Thus, the main purpose of this study was to assess the prevalence of work interruption and associated factors during medication administration process.

METHODS

A prospective, observation-based, cross-sectional study was conducted on 278 nurses. Structure observational sheet was utilized to collect data. EPI Info version 3.5.3 and SPSS version 20 software were utilized for data entry and analysis, respectively. Binary and multivariable logistic regression were fitted to identify the associated factors using an odds ratio and 95% CI.

RESULTS

The incidence of work interruption was found to be 1,152 during medication administration process. Of this, 579 (50.3%) were major/severe work interruptions. Unit of work, day of the week, professional experience, perceived severity of work interruption, source/initiator of interruption, and secondary tasks were factors significantly associated with major work interruptions at p < 0.05.

CONCLUSION

In this study, more than half of work interruption was major/severe. Thus, the authors suggest raising the awareness of nurses regarding the severity of work interruptions, with special attention to those who have lower work experience, sources of interruption, and secondary tasks by assigning additional nurses who manage secondary tasks and supportive supervision.

Physician, Interrupted: Workflow Interruptions and Patient Care in the Emergency Department

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.

The culture contributing to interruptions in the nursing work environment: An ethnography

AIMS AND OBJECTIVES

To understand the occurrence of interruptions within the culture of the medical nursing unit work environment.

BACKGROUND

Interruptions may lead to errors in nursing work. Little is known about how the culture of the nursing work environment contributes to interruptions.

DESIGN

A micro-focused ethnographic study was conducted.

METHOD

Data collection involved extensive observation of a nursing unit, 1:1 observations of nurses and follow-up interviews with the nurses. Data were analysed from unstructured field notes and interview transcripts. The definitions of interruption and culture guided coding, categorising and identification of themes.

RESULTS

A framework was developed that describes the medical nursing unit as a complex culture full of unpredictable, nonlinear changes that affect the entire interconnected system, often in the form of an interruption. The cultural elements contributing to interruptions included (i) the value placed on excellence in patient care and meeting personal needs, (ii) the beliefs that the nurses had to do everything by themselves and that every phone call was important, (iii) the patterns of changing patients, patient transport and coordination of resources and (iv) the normative practices of communicating and adapting.

CONCLUSIONS

Interruptions are an integral part of the culture of a medical nursing unit. Uniformly decreasing interruptions may disrupt current practices, such as communication to coordinate care, that are central to nursing work. In future research, the nursing work environment must be looked at through the lens of a complex system.

RELEVANCE TO CLINICAL PRACTICE

Interventions to minimise the negative impact of interruptions must take into account the culture of the nursing as a complex adaptive system. Nurses should be educated on their own contribution to interruptions and issues addressed at a system level, rather than isolating the interruption as the central issue.

Physician Interruptions and Workload during Emergency Department Shifts

Interruptions in the Emergency Department (ED) are moderately studied in regard to their impact on physicians’ workload. This study captured interruptions characteristics and measures of workload. Twenty-eight ED physicians were followed during their shifts; interruptions they faced were captured using a validated tablet PC-based tool. At the mid and end of their shift, providers completed a NASA-Task Load Index (TLX) questionnaire and a reaction time task. Descriptive statistics and ANOVA were used to identify relationships between physicians’ interruptions and workload. A total of 2355 interruptions were identified ( M =84.1, SD =14.5). The NASA-TLX results showed increase in physicians’ responses for all subscales from mid to end-shifts. Reaction time was higher at end-shift with mean difference of 33.75ms, 95% CI [20.35, 47.13], p < 0.001. At end-shift, there was a statistically significant positive correlation between reaction time and all NASA-TLX subscales. Interruption duration rather than frequency correlated positively with NASA-TLX scores. High/critical interruptions were the least frequent but had longer duration and greater impact on workload. This study provided a unique examination of interruptions over an entire provider shift and identified interruptions as potential causes of increased workload for ED physicians.

Implementation evaluation and refinement of an intervention to improve blunt chest injury management-A mixed-methods study

Aims and objectives

To investigate uptake of a Chest Injury Protocol (ChIP), examine factors influencing its implementation and identify interventions for promoting its use.

Background

Failure to treat blunt chest injuries in a timely manner with sufficient analgesia, physiotherapy and respiratory support, can lead to complications such as pneumonia and respiratory failure and/or death.

Design

This is a mixed‐methods implementation evaluation study.

Methods

Two methods were used: (i) identification and review of the characteristics of all patients eligible for the ChIP protocol, and (ii) survey of hospital staff opinions mapped to the Theoretical Domains Framework (TDF) to identify barriers and facilitators to implementation. The characteristics and treatment received between the groups were compared using the chi‐square test or Fischer's exact test for proportions, and the Mann–Whitney U‐test for continuous data. Quantitative survey data were analysed using descriptive statistics. Qualitative data were coded in NVivo 10 using a coding guide based on the TDF and Behaviour Change Wheel (BCW). Identification of interventions to change target behaviours was sourced from the Behaviour Change Technique Taxonomy Version 1 in consultation with stakeholders.

Results

Only 68.4% of eligible patients received ChIP. Fifteen facilitators and 10 barriers were identified to influence the implementation of ChIP in the clinical setting. These themes were mapped to 10 of the 14 TDF domains and corresponded with all nine intervention functions in the BCW. Seven of these intervention functions were selected to address the target behaviours and a multi‐faceted relaunch of the revised protocol developed. Following re‐launch, uptake increased to 91%.

Conclusions

This study demonstrated how the BCW may be used to revise and improve a clinical protocol in the ED context.

Relevance to clinical practice

Newly implemented clinical protocols should incorporate clinician behaviour change assessment, strategy and interventions. Enhancing the self‐efficacy of emergency nurses when performing assessments has the potential to improve patient outcomes and should be included in implementation strategy.

The Triage Interruptions Assessment Tool: An Instrument Development

Interruptions contribute to catastrophic errors in health care. Interruptions are breaks in the performance of a human activity initiated by a source internal or external to the recipient. Errors during the initial triage assessment can lead to errors in estimating the acuity of a patient and resources required for appropriate care. To advance the science, a valid and reliable instrument to measure this phenomenon is required. The purpose of this mixed-methods/exploratory sequential study was to develop an instrument sensitive to the uniqueness of the triage assessment that would categorize and measure the number and causes of triage interruptions. The study included 3 phases. Phase 1: Qualitative focus groups were used to qualitatively explore interruptions in triage. In Phase 2: Content Validity Assessment, an online survey was used and a content validity index was calculated for each item to determine which items should be modified or removed. A descriptive correlational design was used to assess interrater reliability in Phase 3. Many of the items identified during the focus group sessions were already on the study instrument; some new items were added. Content validity for the entire instrument was 0.82 and increased to 0.91 once irrelevant items were removed. Interrater reliability for the entire instrument demonstrated substantial agreement at 0.773. The study instrument was shown to have strong psychometrics and can be used in practice to better understand what interruptions are occurring in triage and how they affect the triage process.

Ordering Interruptions in a Tertiary Care Center: A Prospective Observational Study

OBJECTIVES

By self-report, interruptions may contribute to up to 80% of ordering errors. A greater understanding of the frequency and context of interruptions during ordering is needed to identify targets for intervention. We sought to characterize the epidemiology of interruptions during order placement in the pediatric inpatient setting.

METHODS

This prospective observational study conducted 1-hour-long structured observations on morning rounds and afternoons and evenings in the resident workroom. The primary outcome was the number of interruptions per 100 orders placed by residents and physician assistants. We assessed the role of ordering provider, number, type and urgency of interruptions and person initiating interruption. Descriptive statistics, χ², and run charts were used.

RESULTS

Sixty-nine structured observations were conducted with a total of 414 orders included. The interruption rate was 65 interruptions per 100 orders during rounds, 55 per 100 orders in the afternoons and 56 per 100 orders in the evenings. The majority of interruptions were in-person (n = 144, 61%). Interruptions from overhead announcements occurred most often in the mornings, and phone interruptions occurred most often in the evenings (P = .002). Nurses initiated interruptions most frequently. Attending physicians and fellows were more likely to interrupt during rounds, and coresidents were more likely to interrupt in the evenings (P = .002).

CONCLUSIONS

Residents and physician assistants are interrupted at a rate of 57 interruptions per 100 orders placed. This may contribute to ordering errors and worsen patient safety. Efforts should be made to decrease interruptions during the ordering process and track their effects on medication errors.

Interruptions of nurses' activities and patient safety: an integrative literature review

OBJECTIVES

to identify characteristics related to the interruption of nurses in professional practice, as well as to assess the implications of interruptions for patient safety.

METHOD

integrative literature review. The following databases were searched: Pubmed/Medline, LILACS, SciELO and Cochrane Library, using the descriptors interruptions and patient safety. An initial date was not established, but the final date was December 31, 2013. A total of 29 papers met the inclusion criteria.

RESULTS

all the papers included describe interruptions as a harmful factor for patient safety. Data analysis revealed three relevant categories: characteristics of interruptions, implications for patient safety, and interventions to minimize interruptions.

CONCLUSION

interruptions favor the occurrence of errors in the health field. Therefore, there is a need for further studies to understand such a phenomenon and its effects on clinical practice.

Traditions of research into interruptions in healthcare: A conceptual review

BACKGROUND

Researchers from diverse theoretical backgrounds have studied workplace interruptions in healthcare, leading to a complex and conflicting body of literature. Understanding pre-existing viewpoints may advance the field more effectively than attempts to remove bias from investigations.

OBJECTIVE

To identify research traditions that have motivated and guided interruptions research, and to note research questions posed, gaps in approach, and possible avenues for future research.

METHODS

A critical review was conducted of research on interruptions in healthcare. Two researchers identified core research communities based on the community's motivations, philosophical outlook, and methods. Among the characteristics used to categorise papers into research communities were the predominant motivation for studying interruptions, the research questions posed, and key contributions to the body of knowledge on interruptions in healthcare. In cases where a paper approached an equal number of characteristics from two traditions, it was placed in a blended research community.

RESULTS

A total of 141 papers were identified and categorised; all papers identified were published from 1994 onwards. Four principal research communities emerged: epidemiology, quality improvement, cognitive systems engineering (CSE), and applied cognitive psychology. Blends and areas of mutual influence between the research communities were identified that combine the benefits of individual traditions, but there was a notable lack of blends incorporating quality improvement initiatives. The question most commonly posed by researchers across multiple communities was: what is the impact of interruptions? Impact was measured as a function of task time or risk in the epidemiology tradition, situation awareness in the CSE tradition, or resumption lag (time to resume an interrupted task) in the applied cognitive psychology tradition. No single question about interruptions in healthcare was shared by all four of the core communities.

CONCLUSIONS

Much research on workplace interruptions in healthcare can be described in terms of fundamental values of four distinct research traditions and the communities that bring the values and methods: of those research traditions to their investigations. Blends between communities indicate that mutual influence has occurred as interruptions research has progressed. It is clear from this review that there is no single or privileged perspective to study interruptions. Instead, these findings suggest that researchers investigating interruptions in healthcare would benefit from being more aware of different perspectives from their own, especially when they consider workplace interventions to reduce interruptions.

Interruptions of activities experienced by nursing professionals in an intensive care unit

OBJECTIVE

to analyze the interruptions experienced by nursing professionals while undertaking care activities.

METHOD

an observational study undertaken in two intensive care units. Two nurses observed 33 nursing professionals for three hours. The data were recorded in real time, using a semistructured instrument.

RESULTS

after 99 hours of observation of 739 activities, it was identified that 46.82% were interrupted, resulting in 7.85 interruptions per hour. On average, the interruptions compromised 9.42% of the nursing professionals' worktime. The activities geared towards indirect care of the patient suffered the highest number of interruptions (56.65%), with the nursing records being the activity interrupted most. The principal source of the interruptions was external, coming from the health professionals (51%), and the main causes were those related to the patients (34.70%) and to interpersonal communication (26.47%).

CONCLUSION

the activity of nursing suffers a high number of interruptions, mainly caused by the health professionals themselves, indicating that the work environment needs to undergo interventions aiming to reduce the risk of compromising of the professional's performance and to increase the patients' safety.

OBJETIVO

analisar as interrupções experienciadas por profissionais de enfermagem durante realização de atividades assistenciais.

MÉTODO

estudo observacional realizado em duas unidades de tratamento intensivo. Dois enfermeiros observaram 33 profissionais de enfermagem, por três horas. Os dados foram registrados em tempo real, usando um instrumento semiestruturado.

RESULTADOS

após 99 horas de observação de 739 atividades, foi identificado que 46,82% sofreram interrupções, perfazendo 7,85 interrupções por hora. As interrupções comprometeram, em média, 9,42% do tempo de trabalho dos profissionais de enfermagem. As atividades direcionadas ao cuidado indireto do paciente foram as que sofreram maior número de interrupções (56,65%), sendo o registro de enfermagem a atividade mais interrompida. A principal fonte das interrupções foi externa, proveniente dos profissionais de saúde (51%), e as principais causas foram as relacionadas aos pacientes (34,70%) e às comunicações interpessoais (26,47%).

CONCLUSÃO

A enfermagem sofre um grande número de interrupções, causadas principalmente pelos próprios profissionais de saúde, indicando que o ambiente de trabalho deve sofrer intervenções que objetivem reduzir o risco de comprometimento do desempenho do profissional e aumentar a segurança dos pacientes.

OBJETIVO

analizar las interrupciones experimentadas por profesionales de enfermería durante la realización de actividades asistenciales.

MÉTODO

estudio observacional realizado en dos unidades de tratamiento intensivo. Dos enfermeros observaron 33 profesionales de enfermería, durante tres horas. Los datos fueron registrados en tiempo real, usando un instrumento semiestructurado.

RESULTADOS

después de 99 horas de observación de 739 actividades, fue identificado que 46,82% sufrieron interrupciones, haciendo 7,85 interrupciones por hora. En promedio, las interrupciones comprometieron 9,42% del tiempo de trabajo de los profesionales de enfermería. Las actividades orientadas al cuidado indirecto del paciente fueron las que sufrieron el mayor número de interrupciones (56,65%), siendo el registro de enfermería la actividad más interrumpida. La principal fuente de interrupciones fue externa, proveniente de los profesionales de la salud (51%), y las principales causas fueron las relacionadas a pacientes (34,70%) y a comunicaciones interpersonales (26,47%).

CONCLUSIÓN

La enfermería sufre un gran número de interrupciones, causadas principalmente por los propios profesionales de la salud, indicando que el ambiente de trabajo debe sufrir intervenciones que objetiven reducir el riesgo de comprometer el desempeño del profesional y aumentar la seguridad de los pacientes.

Factors influencing clinicians' perceptions of interruptions as disturbing or non-disturbing: A qualitative study

OBJECTIVE

Emergency departments consist of multiple systems requiring interaction with one another while still being able to operate independently, creating frequent interruptions in the clinical workflow. Most research on interruptions in health care settings has focused on the relationship between interruptions and negative outcomes. However, there are indications that not all interruptions are negatively perceived by those being interrupted. Therefore, this study aimed to explore factors that influence when a clinician perceives interruptions as non-disturbing or disturbing in an emergency department context.

METHOD

Explorative design based on interviews with 10 physicians and 10 registered nurses at two Swedish emergency departments. Data were analyzed using qualitative content analysis.

RESULT

Factors influencing whether emergency department clinicians perceived interruptions as non-disturbing or disturbing were identified: clinician's constitution, external factors of influence and the nature of the interrupted task. The clinicians' perceptions were related to a complex of attributes inherent in these three factors at the time of the interruption. Thus, the same type of interruption could be perceived as either non-disturbing or disturbing contingent on the surrounding circumstances in which the event occurred.

CONCLUSION

Emergency department clinicians' perceptions of interruptions as non-disturbing or disturbing were related to the character of identified influencing factors.

Emergency department triage performance timing. A regional multicenter descriptive study in Italy

OBJECTIVES

We explored the time employed by nurses to perform the ED triage process in the clinical setting. Moreover, we assessed the influences on triage timing performance exerted by variables related to nurses, local EDs' features, and by interruptions.

METHODS

This is a multicenter prospective descriptive-explorative study performed in 11 EDs of the Tuscany region (Italy), using a 5 tier triage system. The sample was made up of 1/3 of nurses working in each ED. Sampling was performed by a stratified proportional randomization (length of service classes: <5 years; 5-10 years; >10 years). Triage nurses were observed during their triage work-shift.

RESULTS

In 2014, 120 nurses were observed, during 1114 triage processes. The timings of triage phases were: waiting time to triage, median 2.55 min (IQR 1.28-5.03 min; range 0.1-56.25 min); triage duration, median 2.58 min (IQR 1.36-4.35 min; range 0.07-50 min). 400 interruptions were recorded (35.9%). In 9.9% there were 2 interruptions at least. There were significant differences in the medians of triage duration among the years of nurses' triage experience (P < 0.001). The presence of interruption was significantly associated with the increasing of the time intervals in all the triage phases (P < 0.0001). Finally, we recorded significant differences in all the triage time phases between the EDs.

CONCLUSION

We found that the nurses triage time performances are similar to other triage systems in the world.

Assessment of the Impact of Nursing Interruptions on Pharmacist Workflow and Efficiency

Background

Interruptions in the pharmacy setting by nurses are common. While the source of nurse-generated interruptions may be variable, the appropriateness of these interruptions remains unknown.

Objective

To evaluate the impact and appropriateness of nursing interruptions on pharmacist workflow resulting from telephone calls, alphanumeric pagers, and in-person interactions.

Methods

An electronic data collection tool was created to record nursing-based interruptions of pharmacists through telephone calls, pages, and in-person interactions. The data were collected during all pharmacist shifts (day, evening, and night) over 14 days in 2 separate, 7-day data collection periods in December 2011 and January 2012. The data collection form comprised 7 questions that addressed the purpose of this study, including the shift; unit location; type, nature, and appropriateness of the interruption; estimated time spent; and whether the interruption was duplicated.

Results

A total of 3,531 interruptions were documented during the 14 days of data collection; an average of 252 data points per day were recorded by the pharmacists. About 55% of the interruptions were initiated through alphanumeric pagers, 33% from phone calls, and 12% from face-to-face interactions. Sixty-three percent of the total interruptions were annotated as appropriate interruptions, while 37% of were annotated as inappropriate interruptions. The total time spent addressing the interruptions deemed inappropriate was 75 hours during the study period.

Conclusion

Distinct opportunities exist for process improvement changes, as well as educational and behavioral changes, that would greatly benefit nursing and pharmacy staff.

Differentiating between detrimental and beneficial interruptions: a mixed-methods study

INTRODUCTION

Efforts to understand interruptions now span much of the last decade and a half. Often thought to negatively impact patient safety, some now acknowledge that interruptions may be beneficial and actually necessary for safety and high quality care. This study seeks a framework for differentiating between interruptions that are detrimental and those that are beneficial.

METHODS

A mixed-methods approach at a US Level 1 trauma centre included direct observation of 13 registered nurses (RNs), survey of 47 RNs, retrospective observation of hands-free communication devices, and modelling of observed interruptions to key performance measures.

RESULTS

On average, RNs were interrupted every 11 min, with 20.3% of their workload triggered by interruptions. While 85% of RNs agreed that interruptions place their patients at risk, only 21% agreed that all should be eliminated. During one 90-min period, 18 original events spawned 68 interruptions, 50 of these repeat messages. A statistical model, with patient measures of time and comfort, revealed that alarms and call lights returning RN's attention to the patient outside the patient room are beneficial, while interruptions in the patient room are generally detrimental. Triangulating the results, we present an emerging framework for differentiating between beneficial and detrimental interruptions based on the impact of interruptions on the RN's steady treatment and attention to the patient.

CONCLUSIONS

A mixed-methods approach can help distinguish between detrimental and beneficial interruptions. While interruptions breaking the delivery of steady treatment and attention to the patient are detrimental, those returning the RN's focus to the patient, as well as those supporting patient-clinician and clinician-clinician communications are beneficial. This insight may be helpful to healthcare delivery teams tasked with improving interruption-laden processes.

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

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

A comparison of human versus virtual interruptions

Although a wealth of research has examined the effects of virtual interruptions, human-initiated interruptions are common in many work settings. An experiment compared performance on a primary data-entry task during human-initiated (human) versus computer-initiated (virtual) interruptions. Participants completed blocks of trials that featured either an interruption from a computer or an interruption from a human experimenter. The timing of the onset of the interruptions was also varied across trials. Human interruptions resulted in much shorter interruption lags. No significant differences were observed for the number of correct responses on the primary task for human versus virtual interruptions, but interruptions that occurred later in the task sequence resulted in fewer mistakes. The social aspect of human interruptions may have attenuated interruption lags in that condition, and it is possible that virtual interruptions may permit people greater temporal flexibility in managing their engagement with interruptions.

The impact of intra-operative interruptions on surgeons' perceived workload: an observational study in elective general and orthopedic surgery

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.