A survey of wellness issues in emergency medicine (Part 2)

System complexity as a measure of safe capacity for the emergency department

OBJECTIVES

System complexity is introduced as a new measure of system state for the emergency department (ED). In its original form, the measure quantifies the uncertainty of demands on system resources. For application in the ED, the measure is being modified to quantify both workload and uncertainty to produce a single integrated measure of system state.

METHODS

Complexity is quantified using an information-theoretic or entropic approach developed in manufacturing and operations research. In its original form, complexity is calculated on the basis of four system parameters: 1) the number of resources (clinicians and processing entities such as radiology and laboratory systems), 2) the number of possible work states for each resource, 3) the probability that a resource is in a particular work state, and 4) the probability of queue changes (i.e., where a queue is defined by the number of patients or patient orders being managed by a resource) during a specified time period.

RESULTS

An example is presented to demonstrate how complexity is calculated and interpreted for a simple system composed of three resources (i.e., emergency physicians) managing varying patient loads. The example shows that variation in physician work states and patient queues produces different scores of complexity for each physician. It also illustrates how complexity and workload differ.

CONCLUSIONS

System complexity is a viable and technically feasible measurement for monitoring and managing surge capacity in the ED.

Intimate partner sexual assault against women and associated victim substance use, suicidality, and risk factors for femicide

In order to establish the frequency of substance use, following and attributed to sexual assault, and describe the danger for femicide and suicidality for women physically and sexually abused compared to physically-abused only women, a personal interview of 148 African-American, Hispanic, and white English and Spanish-speaking abused women was completed. Women who reported more than one sexual assault were 3.5 (95% CI, 0.9, 13.4) times more likely to report beginning or increasing substance use compared to women who reported only one sexual assault. Sexually assaulted women reported significantly (p=.002) more risk factors for femicide compared to physically- abused only women. Specific to suicide, women reporting sexual assault were 5.3 (95% CI, 1.3, 21.5) times more likely to report threatening or attempted suicide within a 90-day period compared to physically-abused only women. The health assessment and intervention of intimate partner violence must extend beyond injury to include behavior risk sequelae of substance abuse and suicidality.

Emergency physicians’ behaviors and workload in the presence of an electronic whiteboard

BACKGROUND

As the demands on the emergency medicine (EM) system continue to increase, improvements in the organization of work and the access to timely clinical and system information will be required for providers to manage their workload in a safe and efficient manner. Information technology (IT) solutions are beginning to find their place in the emergency department (ED) and it is time to begin understanding how these systems are effecting physician behavior, communication and workload.

METHODS

The study used a time-in-motion, primary task analyses to study faculty and resident physician behavior in the presence of an electronic whiteboard. The NASA-Task Load Index (TLX) was used to measure subjective workload and the underlying dimensions of workload at the end of each physician observation. Work, communication and workload were characterized using descriptive statistics and compared using Mann-Whitney U-tests.

RESULTS

Physicians in our study performed more tasks and were interrupted less than physicians studied previously in conventional EDs. Interruptions interrupted direct patient care tasks less than other clinical activities. Temporary interruptions appear to be a major source of inefficiency in the ED, and likely a major threat to patient safety. Face-to-face interruptions persist even in the presence of advanced IT systems, such as the electronic whiteboard. Faculty physicians exhibited lower workload scores than resident physicians. Frustration was a significant contributing factor to workload in resident physicians. All physicians ranked temporal demands and mental demands as major contributing factors to workload.

CONCLUSION

The results indicate that the electronic whiteboard improves the efficiency of work and communication in the ED. IT solutions may have great utility in improving provider situational awareness and distributing workload among ED providers. The results also demonstrate that IT solutions alone will not solve all problems in the ED. IT solutions will probably be most effective in improving efficiency and safety outcomes when paired with human-based interventions, such as crew resource management. Future studies must investigate team interaction, workload and situational awareness, and the association of these factors to patient and provider outcomes.

Noise in the ED

BACKGROUND

The impact of noise pollution on both the patient and the care provider has been extensively studied in the neonatal intensive care unit and in other critical care units. Noise pollution makes errors more probable and is one of the risk factors for provider burnout and negative outcomes for patients. The Environmental Protection Agency (EPA) recommends that the acceptable noise level in a hospital should not exceed 40 dB.

OBJECTIVES

The purpose of this study was to record and analyze noise in a large urban level I emergency department (ED) and compare to the EPA guidelines.

METHODS

A 3-channel dosimeter Quest Q300 (Quest Technologies, Oconomowoc, WI) was placed as a stand-alone unit on the wall of the resuscitation booth in the ED. Sound was sampled 16 times per second for 12 hours and was recorded as peaks and averages for each minute. The dosimeter was then placed in the pocket of a medical student with a small 8-mm shoulder-mount type 2 microphone. The medical student followed an emergency medicine resident throughout an 8-hour shift in the main resuscitation area while monitoring and logging sound fluctuations in the environment. Sound pressure levels were logged in real time and subsequently correlated to the recorded peaks. Sound was sampled 16 times per second and recorded peaks and averages for each minute.

RESULTS

In the initial part of the study, the time-weighted average was 43 dB. The average sound levels peaked approximately 25 times over 12 hours. Individually measured peak levels of 94 to 117 dB occurred every minute. In the second part of the study, the time-weighted average was 52.9 dB.

CONCLUSIONS

When compared to EPA accepted noise levels for hospital (40 dB), the ED under study had excessive noise on a regular basis. There are easily identifiable sources of noise pollution in the ED. By identifying and modifying sources of noise, stress in the ED may be decreased.