Interruptions in emergency department work: an observational and interview study

The scope of emergency nursing viewed through the lens of complex adaptive systems: A discussion paper

Across the world, emergency department nurses care for patients around the clock all year long. They perform tasks ranging from direct nursing care to managing patient flow, working in an environment characterised by interdependencies among numerous actors. The complex context in which emergency nurses operate has not been thoroughly described or discussed, indicating a knowledge gap. Hence, the aim of this discussion paper is to describe and discuss nursing in the emergency department and the connection between patient flow and nursing care, drawing on the concept of complex adaptive systems. The acts of direct patient care and patient flow, when viewed through the lens of complex adaptive systems, are central components of emergency nursing. Through a stepwise description of these two perspectives, based on literature and clinical experience from European countries, the paper illustrates the complexity of the emergency nursing context in a novel manner. We argue that direct patient care and patient flow, combined as patient flow management, constitute essential parts of the core of emergency department nursing. Further studies are needed to challenge or confirm this assertion.

Designing Health Care Provider-Centered Emergency Department Interventions: Participatory Design Study

BACKGROUND

In the emergency department (ED), health care providers face extraordinary pressures in delivering accurate diagnoses and care, often working with fragmented or inaccessible patient histories while managing severe time constraints and constant interruptions. These challenges and pressures may lead to potential errors in the ED diagnostic process and risks to patient safety. With advances in technology, interventions have been developed to support ED providers in such pressured settings. However, these interventions may not align with the current practices of ED providers. To better design ED provider-centered interventions, identifying their needs in the diagnostic process is critical.

OBJECTIVE

This study aimed to identify ED providers' needs in the diagnostic process through participatory design sessions and to propose design guidelines for provider‑centered technological interventions that support decision‑making and reduce errors.

METHODS

We conducted a participatory design study with ED providers to validate their needs and identify considerations for designing ED provider-centered interventions to improve diagnostic safety. We used 9 technological intervention ideas as storyboards to address the study participants' needs. We had participants discuss the use cases of each intervention idea to assess their needs during the ED care process and facilitated co-design activities with the participants to improve the technological intervention designs. We audio- and video-recorded the design sessions. We then analyzed session transcripts, field notes, and design sketches. In total, we conducted 6 design sessions with 17 ED frontline providers.

RESULTS

Through design sessions with ED providers, we identified 4 key needs in the diagnostic process: information integration, patient prioritization, ED provider-patient communication, and care coordination. We interpreted them as insights for designing technological interventions for ED patients. Hence, we discussed the design implications for technological interventions in four key areas: (1) enhancing ED provider-ED provider communication, (2) enhancing ED provider-patient communication, (3) optimizing the integration of advanced technology, and (4) unleashing the potential of artificial intelligence tools in the ED to improve diagnosis. This work offers evidence-based technology design suggestions for improving diagnostic processes.

CONCLUSIONS

This study provides unique insights for designing technological interventions to support ED diagnostic processes. By inviting ED providers into the design process, we present unique insights into the diagnostic process and design considerations for designing novel technological interventions that meet ED providers' needs in the diagnostic process.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/55357.

Discharge communication during transitions from emergency care to home

The healthcare system in Canada is overwhelmed and requires reform. Good discharge communication is a cornerstone of patient safety and quality care. In the Emergency Department (ED), good discharge communication means that patients leave with a clear understanding of their health condition, and the steps they need to take to continue their recovery at home. The fragmented nature of communication in the ED coupled with long wait times and high noise levels pose significant risks to the continuity of information exchange. Additional communication barriers arise for many patients due to a lack of control, language differences, low health literacy, and feelings of fear and uncertainty. Multiple interventions have been evaluated to improve ED discharge communication, but further work is needed to engage all end users in a theory-based approach. Addressing challenges related to successful discharge communication requires a multifaceted approach that includes improving institutional policies, adopting innovative co-designed interventions, and leveraging technology.

Academic hospitalist perspectives on the benefits and challenges of secure messaging: A mixed methods analysis

BACKGROUND

Hospitals and patients rely on effective clinician communication. Asynchronous electronic secure messaging (SM) systems are a common way for hospitalists to communicate, but few studies have evaluated how hospitalists are navigating the adoption of SM and the benefits and challenges they are encountering.

OBJECTIVES

The objective of this study is to assess academic hospitalist perspectives on SM to guide future research and quality improvement initiatives.

METHODS

This was a mixed methods study utilizing an embedded REDCap survey and six virtual semistructured focus groups. It took place during a Hospital Medicine ReEngineering Network Zoom meeting on October 13, 2023. Rapid qualitative methods were used to define major themes.

RESULTS

There were 28 hospitalists and one patient representative across 24 separate academic institutions. There was a 71% survey completion rate (N = 20). SM was felt to be an effective and efficient communication modality but was associated with a large amount of multitasking and interruptions. Perspectives around SM clustered around three main themes: SM has been widely but variably adopted; there is a lack of institutional guidance about how to best engage with SM; and SM is changing the landscape of hospitalist work by increasing ease but decreasing depth of communication, increasing cognitive load, and changing interpersonal relationships. Recommendations for SM improvements included the need for institutions to work with frontline workers to develop and implement clear usage guidelines.

CONCLUSION

SM is likely contributing to both positive and negative effects for clinicians and patients. Understanding hospitalist perspectives on SM will help guide future research and quality improvement initiatives.

Implementation of Electronic Triggers to Identify Diagnostic Errors in Emergency Departments

Importance

Missed diagnosis can lead to preventable patient harm.

Objective

To develop and implement a portfolio of electronic triggers (e-triggers) and examine their performance for identifying missed opportunities in diagnosis (MODs) in emergency departments (EDs).

Design, Setting, and Participants

In this retrospective medical record review study of ED visits at 1321 Veterans Affairs health care sites, rules-based e-triggers were developed and implemented using a national electronic health record repository. These e-triggers targeted 6 high-risk presentations for MODs in treat-and-release ED visits. A high-risk stroke e-trigger was applied to treat-and-release ED visits from January 1, 2016, to December 31, 2020. A symptom-disease dyad e-trigger was applied to visits from January 1, 2018, to December 31, 2019. High-risk abdominal pain, unexpected ED return, unexpected hospital return, and test result e-triggers were applied to visits from January 1, 2019, to December 31, 2019. At least 100 randomly selected flagged records were reviewed by physician reviewers for each e-trigger. Data were analyzed between January 2024 and April 2024.

Exposures

Treat-and-release ED visits involving high-risk stroke, symptom-disease dyads, high-risk abdominal pain, unexpected ED return, unexpected hospital return, and abnormal test results not followed up after initial ED visit.

Main Outcomes and Measures

Trained physician reviewers evaluated the presence/absence of MODs at ED visits and recorded data on patient and clinician characteristics, types of diagnostic process breakdowns, and potential harm from MODs.

Results

The high-risk stroke e-trigger was applied to 8 792 672 treat-and-release ED visits (4 967 283 unique patients); the symptom-disease dyad e-trigger was applied to 3 692 454 visits (2 070 979 patients); and high-risk abdominal pain, unexpected ED return, unexpected hospital return, and test result e-triggers were applied to 1 845 905 visits (1 032 969 patients), overall identifying 203, 1981, 170, 116 785, 14 879, and 2090 trigger-positive records, respectively. Review of 625 randomly selected patient records (mean [SD] age, 62.5 [15.2] years; 553 [88.5%] male) showed the following MOD counts and positive predictive values (PPVs) within each category: 47 MODs (PPV, 47.0%) for stroke, 31 MODs (PPV, 25.8%) for abdominal pain, 11 MODs (PPV, 11.0%) for ED returns, 23 MODs (PPV, 23.0%) for hospital returns, 18 MODs (PPV, 18.0%) for symptom-disease dyads, and 55 MODs (PPV, 52.4%) for test results. Patients with MODs were slightly older than those without (mean [SD] age, 65.6 [14.5] vs 61.2 [15.3] years; P < .001). Reviewer agreement was favorable (range, 72%-100%). In 108 of 130 MODs (83.1%; excluding MODs related to the test result e-trigger), the most common diagnostic process breakdown involved the patient-clinician encounter. In 185 total MODs, 20 patients experienced severe harm (10.8%), and 54 patients experienced moderate harm (29.2%).

Conclusions and Relevance

In this retrospective medical record review study, rules-based e-triggers were useful for post hoc detection of MODs in ED visits. Interventions to target ED work system factors are urgently needed to support patient-clinician encounters and minimize harm from diagnostic errors.

Root causes behind patient safety incidents in the emergency department and suggestions for improving patient safety - an analysis in a Finnish teaching hospital

BACKGROUND

Adverse events occur frequently at emergency departments (ED) because of several risk factors related to varying conditions. It is still unclear, which factors lead to patient safety incident reports. The aim of this study was to explore the root causes behind ED-associated patient safety incidents reported by personnel, and based on the findings, to suggest learning objectives for improving patient safety.

METHODS

The study material included incident reports (n = 340) which concerned the ED of a teaching hospital over one year. We used a mixed method combining quantitative descriptive statistics and qualitative research by inductive content analysis and deductive Ishikawa root cause analysis.

RESULTS

Most (76.5%) incidents were reported after patient transfer from the ED. Nurses reported 70% of incidents and physicians 7.4%. Of the reports, 40% were related to information flow or management. Incidents were evaluated as no harm (29.4%), mild (46%), moderate (19.7%), and severe (1.2%) harm to the patient. The main consequences for the organization were reputation loss (44.1%) and extra work (38.9%). In the qualitative analysis, nine specific problem groups were found: insufficient introduction, adherence to guidelines and protocols, insufficient human resources, deficient professional skills, medication management deficiencies, incomplete information transfer from the ED, language proficiency, unprofessional behaviour, identification error, and patient-dependent problems. Six organizational themes were identified: medical staff orientation, onboarding and competence requirements; human resources; electronic medical records and information transfer; medication documentation system; interprofessional collaboration; resources for specific patient groups such as geriatric, mental health, and patients with substance abuse disorder. Entirely human factor-related themes could not be defined because their associations with system factors were complex and multifaceted. Individual and organizational learning objectives were addressed, such as adherence to the proper use of instructions and adequate onboarding.

CONCLUSIONS

System factors caused most of the patient safety incidents reported concerning ED. The introduction and training of ED -processes is elementary, as is multiprofessional collaboration. More research is needed about teamwork skills, patients with special needs and non-critical patients, and the reporting of severe incidents.

How do emergency departments respond to ambulance pre-alert calls? A qualitative exploration of the management of pre-alerts in UK emergency departments

BACKGROUND

Calls to emergency departments (EDs) from ambulances to alert them to a critical case being transported to that facility that requires a special response ('pre-alerts') have been shown to improve outcomes for patients requiring immediate time-critical treatment (eg, stroke). However, little is known about their usefulness for other patients and the processes involved in ED responses to them. This study aimed to understand how pre-alerts influence patient care in the ED.

METHODS

We undertook non-participant observation (162 hours, 143 pre-alerts) and semi-structured interviews with staff (n=40) in six UK EDs between August 2022 and April 2023 focusing on how ED staff respond to pre-alert calls and what influences their response. Observation notes and interview transcripts were imported into NVivo and analysed using a thematic approach.

RESULTS

Pre-alert calls involved significant time and resources for ED staff but they were valued as they enabled staff to prepare for a patient's arrival (practically and psychologically). High demand and handover delays at ED created additional pre-alerts due to ambulance clinician concerns about the impact of long waits on patients.Despite the risk of pre-alert fatigue from calls for patients considered not to require a special response, ED clinicians appreciated timely pre-alert information, perceiving a higher risk from underalerting than overalerting. Variation in ED response was influenced by individual and organisational factors, particularly the resources available at the time of pre-alert. Unclear ED processes for receiving, documenting and sharing information about pre-alerts increased the risk of information loss.

CONCLUSION

Improving processes for receiving and sharing pre-alert information may help ED clinicians prepare appropriately for incoming patients. Alternative routes for ambulance clinicians to seek advice on borderline pre-alert patients may help to improve the appropriateness of pre-alerts.

Interruptions during general practice consultations: negative impact on physicians, and patients' indifference

BACKGROUND

Interruptions can impact consultation duration, doctors and patients' satisfaction, and quality of care provided. Although most of them seem to have a negative impact, affecting doctor-patient relationship and interfering with clinical reasoning, which increases the risk of error, there is still no evidence on their global impact on consultations.

OBJECTIVES

To evaluate the number and duration of interruptions during general practice consultations. To compare physicians and patients' perceptions of their urgency and impact, as well as the overall satisfaction with the consultation.

METHODS

Cross-sectional study of a representative sample of annual face-to-face general practice consultations at a Health Centre. Between January and March 2022, anonymous questionnaires were given to physicians and patients after consultation. We performed a descriptive and inferential statistical analysis.

RESULTS

A total of 403 consultations were included. Physicians reported more interruptions than patients (108 vs. 87, P < 0.001). From patients' perspective those interruptions were more urgent (34.5%) compared with physicians' perspective (20.6%; P = 0.029). Patients undervalued their impact on consultations (7.1% of interruptions with a negative impact among patients vs. 24.7% among doctors; P < 0.001). Interruptions did not interfere with patients' satisfaction with consultation (P = 0.135) but were associated with lower physicians' satisfaction with consultation (P = 0.003).

CONCLUSION

Physicians are more critical regarding consultations interruptions, being more aware of their incidence and reporting more often a negative impact, which translates into lower satisfaction with interrupted consultations. Patients devalue the occurrence of interruptions, showing no concern about their impact on security or privacy, and their satisfaction is not affected by them.

Refining a Framework to Enhance Communication in the Emergency Department During the Diagnostic Process: An eDelphi Approach

BACKGROUND

Emergency departments (EDs) are susceptible to diagnostic error. Suboptimal communication between the patient and the interdisciplinary care team increases risk to diagnostic safety. The role of communication remains underrepresented in existing diagnostic decision-making conceptual models.

METHODS

The authors used eDelphi methodology, whereby data are collected electronically, to achieve consensus among an expert panel of 18 clinicians, patients, family members, and other participants on a refined ED-based diagnostic decision-making framework that integrates several potential opportunities for communication to enhance diagnostic quality. This study examined the entire diagnostic process in the ED, from prehospital to discharge or transfer to inpatient care, and identified where communication breakdowns could occur. After four iterative rounds of the eDelphi process, including a final validation round by all participants, the project's a priori consensus threshold of 80% agreement was reached.

RESULTS

The authors developed a final framework that positions communication more prominently in the diagnostic process in the ED and enhances the original National Academies of Sciences, Engineering, and Medicine (NASEM) and ED-adapted NASEM frameworks. Specific points in the ED journey were identified where more attention to communication might be helpful. Two specific types of communication-information exchange and shared understanding-were identified as high priority for optimal outcomes. Ideas for communication-focused interventions to prevent diagnostic error in the ED fell into three categories: patient-facing, clinician-facing, and system-facing interventions.

CONCLUSION

This project's refinement of the NASEM framework adapted to the ED can be used to develop communications-focused interventions to reduce diagnostic error in this highly complex and error-prone setting.

A New Perspective on Missed Nursing Care in the Emergency Department: A Descriptive Cross-Sectional Study

INTRODUCTION

This descriptive cross-sectional study describes missed nursing care, quality of care, and patient safety rated by nursing staff in emergency departments. Required patient care that is omitted or delayed (missed nursing care) is associated with poorer quality of care and increased risk for adverse events, but studies are scarce in the emergency setting.

METHODS

Emergency registered nurses and nursing assistants (N=126) at 2 Swedish emergency departments participated in the study. The MISSCARE survey-Swedish version was used for data collection.

RESULTS

Emergency nursing staff assessed that nursing care is frequently missed in the emergency department. More than half of the 24 nursing care items were reported as missed by over 50% of the participants, and registered nurses rated most items significantly higher compared to nursing assistants. Half of the nursing staff perceived quality of care to be good, but nearly the same proportion perceived patient safety as poor. Registered nurses viewed both quality and safety worse than nursing assistants.

DISCUSSION

The present study found very high levels of missed nursing care in most nursing items. Results indicate that nursing staff in emergency departments need to prioritize between the tasks and that some tasks may not be relevant in the context. The emergency setting focuses primarily on identifying signs of urgency, assessing patients, performing interventions, and diagnostics. However, even items that seemed to be prioritized, such as reassessment of vital signs, had a surprisingly high level of missed nursing care in comparison to in-hospital wards.

Telemedicine vs Telephone Consultations and Medication Prescribing Errors Among Referring Physicians: A Cluster Randomized Crossover Trial

Importance

Critically ill children presenting to emergency departments (EDs) in non-children's hospitals are at high risk for experiencing medical errors, including medication errors. Video telemedicine consultations with pediatric specialists have the potential to reduce the risk of medication errors beyond the current standard of care, telephone consultations.

Objective

To compare the rates of ED physician-related medication errors among critically ill children randomized to receive either video telemedicine or telephone consultations.

Design, Setting, and Participants

This cluster randomized, unbalanced crossover trial was conducted at 15 community EDs in northern California between September 2014 and March 2018. Analyses were conducted from May 2022 to January 2023. Participants included acutely ill children younger than 15 years presenting to a participating ED.

Interventions

Participating EDs were randomized to use video telemedicine or telephone for consultations with pediatric critical care physicians according to 1 of 4 unbalanced (3 telemedicine to 1 telephone) crossover treatment assignment sequences.

Main Outcomes and Measures

Pharmacists reviewed medical records to document physician-related medication errors using a previously validated instrument. Multilevel logistic regression analyses were performed to create models with the medication order as the unit of analysis and adjusting for age, the log-transformed Revised Pediatric Emergency Assessment Tool score, and hospital study period.

Results

A total of 696 patient encounters were included in the trial (mean [SD] age, 4.2 [4.6] years; median [IQR] age, 2.1 [0.5-2.1] years; 304 female [43.7%]), with 537 patient encounters (77.2%) assigned to video telemedicine and 159 patient encounters (22.8%) assigned to telephone. At least 1 physician-related medication error occurred for 87 patients (12.5%), including 20 of 159 patients (12.6%) in the telephone cohort and 67 of 537 patients (12.5%) in the telemedicine cohort. Of the 2414 medication orders, errors occurred in 124 cases (5.1%), including 26 of 513 orders (5.1%) in the telephone cohort and 98 of 1901 orders (5.2%) in the telemedicine cohort. In the multivariable analysis, the adjusted odds ratio of experiencing a medication error among those assigned to telemedicine was 0.86 (95% CI, 0.49-1.52; P = .61).

Conclusions and Relevance

This cluster randomized crossover trial found no statistically significant differences in physician-related medication errors between critically ill children assigned to receive telephone consultations vs video telemedicine consultations.

Trial Registration

ClinicalTrials.gov Identifier: NCT02877810.

A Novel Algorithm for Improving the Prehospital Diagnostic Accuracy of ST-Segment Elevation Myocardial Infarction

INTRODUCTION

Early detection of ST-segment elevation myocardial infarction (STEMI) on the prehospital electrocardiogram (ECG) improves patient outcomes. Current software algorithms optimize sensitivity but have a high false-positive rate. The authors propose an algorithm to improve the specificity of STEMI diagnosis in the prehospital setting.

METHODS

A dataset of prehospital ECGs with verified outcomes was used to validate an algorithm to identify true and false-positive software interpretations of STEMI. Four criteria implicated in prior research to differentiate STEMI true positives were applied: heart rate <130, QRS <100, verification of ST-segment elevation, and absence of artifact. The test characteristics were calculated and regression analysis was used to examine the association between the number of criteria included and test characteristics.

RESULTS

There were 44,611 cases available. Of these, 1,193 were identified as STEMI by the software interpretation. Applying all four criteria had the highest positive likelihood ratio of 353 (95% CI, 201-595) and specificity of 99.96% (95% CI, 99.93-99.98), but the lowest sensitivity (14%; 95% CI, 11-17) and worst negative likelihood ratio (0.86; 95% CI, 0.84-0.89). There was a strong correlation between increased positive likelihood ratio (r2 = 0.90) and specificity (r2 = 0.85) with increasing number of criteria.

CONCLUSIONS

Prehospital ECGs with a high probability of true STEMI can be accurately identified using these four criteria: heart rate <130, QRS <100, verification of ST-segment elevation, and absence of artifact. Applying these criteria to prehospital ECGs with software interpretations of STEMI could decrease false-positive field activations, while also reducing the need to rely on transmission for physician over-read. This can have significant clinical and quality implications for Emergency Medical Services (EMS) systems.

Do human work interruptions bring positive affective responses?-Based on the mediation of coping potential and the moderation of polychronicity

This research aims to investigate the impact of human work interruptions on positive affective responses and their underlying mechanisms in the Chinese context. In the first stage, this study conducted face-to-face semi-structured interviews with 29 employees representing diverse industries. The grounded theory research method was used to extract the construct of human work interruption, identify its core attributes, and capture the naturally emerging storyline of "human work interruptions - coping potential - polychronicity - positive affective responses". In the second stage, a theoretical model was constructed and validated using 362 questionnaires. The results indicate that in the Chinese context: (1) human work interruptions can trigger positive affective responses; (2) coping potential mediates the relationship between human work interruptions and positive affective responses; (3) when individuals have a higher level of polychronicity, the impact of human work interruptions on positive affective responses via coping potential is enhanced. The findings of this study effectively address the hypothesis of the "positive aspect" of work interruptions proposed by management scholars and contribute to the existing literature on work interruptions and positive affective responses. Moreover, this research provides practical and theoretical implications for managers and employees in managing and coping with human work interruptions.

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

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

Peer recovery coaches and emergency department utilization in patients with substance use disorders

BACKGROUND

Although Emergency Departments (ED) frequently provide care for patients with substance use disorders (SUD), there are many barriers to connecting them with appropriate long-term treatment. One approach to subside risk in this population is the Peer Recovery Coach (PRC). PRCs are individuals with a lived experience of the rehabilitation process and are a powerful resource to bridge this gap in care by engaging patients and their families and providing system navigation, self-empowerment for behavior change, and harm reduction strategies. The purpose of this project is to describe an ED-based PRC program, evaluating its feasibility and efficacy.

METHODS

This was a retrospective quality improvement project conducted at 3 suburban hospitals. All patients arriving to the ED were screened with a brief questionnaire in triage and patients identified as a high-risk had referral placed to a PRC if the patient consented. The PRC met with the patient at the ED bedside if possible. The PRC program members collected prospective data on patient engagement with the PRC at 30, 60, and 90 days post ED encounter. Using the EMR we identified the number of subsequent ED visits at 30, 60, and 90 days (for both medical and substance use disorder-related visits) from the index PRC visit.

RESULTS

There were 448 individuals identified and included in this analysis between January 1, 2019 and June 30, 2020, of which 292 (66%) were male and the mean age was 44 (range 18-80). Most patients identified alcohol as the primary substance they used (289, 65%), followed by heroin/opiates (20%). At 30, 60, and 90 days, there were 110 (25%), 79 (18%), and 71 (16%) patients who were still actively engaged in the program, respectively. Among all patients in the cohort, there was essentially no decrease in mean visits before versus after the PRC engagement visit. However, among patients who had at least one prior ED visit, there were significant differences in mean visits across all visit-types: for patients with 1 prior ED visit, 90 day mean decrease in visits = 1.0 visits (95% CI 0.7-1.2), for patients with 5+ prior ED visits, 90 day mean decrease in visits = 3.6 visits (95% CI 2.4-4.8).

CONCLUSION

We describe the implementation of an ED-based PRC program for patients with substance use disorders. While we demonstrated that it is feasible for the PRC to engage the patient while in the ED, there was poor follow-up with the program outpatient. For patients with at least one previous SUD visit to the ED, there was a statistically significant reduction in ED utilization after engaging with a PRC while in the ED, suggesting this may be a population that could be targeted to link patients to long term care and decrease repeated ED utilization.

A Machine Learning Approach to Support Urgent Stroke Triage Using Administrative Data and Social Determinants of Health at Hospital Presentation: Retrospective Study

BACKGROUND

The key to effective stroke management is timely diagnosis and triage. Machine learning (ML) methods developed to assist in detecting stroke have focused on interpreting detailed clinical data such as clinical notes and diagnostic imaging results. However, such information may not be readily available when patients are initially triaged, particularly in rural and underserved communities.

OBJECTIVE

This study aimed to develop an ML stroke prediction algorithm based on data widely available at the time of patients' hospital presentations and assess the added value of social determinants of health (SDoH) in stroke prediction.

METHODS

We conducted a retrospective study of the emergency department and hospitalization records from 2012 to 2014 from all the acute care hospitals in the state of Florida, merged with the SDoH data from the American Community Survey. A case-control design was adopted to construct stroke and stroke mimic cohorts. We compared the algorithm performance and feature importance measures of the ML models (ie, gradient boosting machine and random forest) with those of the logistic regression model based on 3 sets of predictors. To provide insights into the prediction and ultimately assist care providers in decision-making, we used TreeSHAP for tree-based ML models to explain the stroke prediction.

RESULTS

Our analysis included 143,203 hospital visits of unique patients, and it was confirmed based on the principal diagnosis at discharge that 73% (n=104,662) of these patients had a stroke. The approach proposed in this study has high sensitivity and is particularly effective at reducing the misdiagnosis of dangerous stroke chameleons (false-negative rate <4%). ML classifiers consistently outperformed the benchmark logistic regression in all 3 input combinations. We found significant consistency across the models in the features that explain their performance. The most important features are age, the number of chronic conditions on admission, and primary payer (eg, Medicare or private insurance). Although both the individual- and community-level SDoH features helped improve the predictive performance of the models, the inclusion of the individual-level SDoH features led to a much larger improvement (area under the receiver operating characteristic curve increased from 0.694 to 0.823) than the inclusion of the community-level SDoH features (area under the receiver operating characteristic curve increased from 0.823 to 0.829).

CONCLUSIONS

Using data widely available at the time of patients' hospital presentations, we developed a stroke prediction model with high sensitivity and reasonable specificity. The prediction algorithm uses variables that are routinely collected by providers and payers and might be useful in underresourced hospitals with limited availability of sensitive diagnostic tools or incomplete data-gathering capabilities.

Explaining emergency physicians' capacity to recover from interruptions

OBJECTIVE

To assess whether the capacity to utilize cues amongst emergency physicians is associated with differences in the capacity to recover performance following an interruption.

BACKGROUND

Interruptions are implicated in errors in emergency medicine due to the cognitive load that they impose on working memory, resulting in a loss of performance on the primary task. The utilization of cues is associated with a reduction in cognitive load during the performance of a task, thereby enabling the allocation of residual resources that mitigates the loss of performance following interruptions.

METHOD

Thirty-nine emergency physicians, recruited at a medical conference, completed an assessment of cue utilization (EXPERTise 2.0) and an online simulation (Septris) that involved the management of patients presenting with sepsis. During the simulation, physicians were interrupted and asked to check a medication order. Task performance was assessed using scores on Septris, with points awarded for the accurate management of patients.

RESULTS

Emergency physicians with higher cue utilization recorded significantly higher scores on the simulation task following the interruption, compared to physicians with lower cue utilization (p = .028).

CONCLUSION

The results confirm a relationship between cue utilization and the recovery of performance following an interruption. This is likely due to the advantages afforded by associated reductions in cognitive load.

APPLICATION

Assessments of cue utilization may assist in the development of interventions to support clinicians in interruptive environments.

Development and Validation of a Nursing Work Interruption Scale

Work interruption disturbs nurses' flow of thinking, diminishes work efficiency, induces burnout, and causes errors that can threaten patients' lives. Therefore, it is important to identify the causes and measure the extent of work interruption. This study developed a self-report scale and established its validity and reliability for use in hospital settings. Through literature review and in-depth interviews with nurses, we identified two components and developed 25 preliminary items. These items were reviewed by nursing experts for content validity and pilot tested among 20 hospital nurses; subsequently, a 16-item preliminary instrument was finalized. A total of 359 questionnaires were included in the final analysis, and exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were performed. Two factors and 12 items were derived from two rounds of EFA, with a cumulative percentage of variance of 55.73%. Construct validity was established through CFA. The predictive validity and internal consistency reliability of the developed scale were also established. Thus, the 12-item Work Interruption Measurement Scale for Nurses comprising two domains (human and environmental factors) was developed. This scale can be useful in assessing work interruption experienced by nurses and for developing and assessing the effectiveness of interventions pertaining to nurses' work interruption.

Impact of workflow interruptions on baseline activities of the doctors working in the emergency department

Background

Workflow interruptions are common in the emergency department (ED) of the hospitals for physicians, leading to an increased risk of errors.

Purpose

This study aims to understand the baseline activities of the ED doctors and how these are affected by workflow interruptions.

Methods

The study was conducted in two phases to collect the doctor’s perspective (through questionnaire survey) and observer’s perspective (through workflow observation study) about ED doctors’ baseline activities and workflow interruptions. Two different perspectives were obtained to make the insights clearer and more valuable. The point of view of the 223 doctors working in ED of the hospitals was recorded through a questionnaire survey. In the second phase, the observer’s point of view (authors) was obtained through a workflow observation study, and 13 doctors were observed for 160 hours.

Results

Direct communication with patients (37.1%) and ‘documentation and prescription’ (22.7%) were found to be the most frequent activities. The most common interruptions were visual and auditory distractions, rumination (mind-wandering) and intrusion (by co-workers). Also, the time consumed on indirect patient care (6.6%) was higher than direct patient care (4. 2%). Interruptions increase the chances of errors by making it hard for a doctor to resume a primary task after facing interruptions.

Conclusion

Interruptions increase the chances of errors and make it difficult for the doctors to resume primary tasks (after facing such incidents).

Cognitive biases encountered by physicians in the emergency room

Background

Diagnostic errors constitute an important medical safety problem that needs improvement, and their frequency and severity are high in emergency room settings. Previous studies have suggested that diagnostic errors occur in 0.6-12% of first-time patients in the emergency room and that one or more cognitive factors are involved in 96% of these cases. This study aimed to identify the types of cognitive biases experienced by physicians in emergency rooms in Japan.

Methods

We conducted a questionnaire survey using Nikkei Medical Online (Internet) from January 21 to January 31, 2019. Of the 159,519 physicians registered with Nikkei Medical Online when the survey was administered, those who volunteered their most memorable diagnostic error cases in the emergency room participated in the study. EZR was used for the statistical analyses.

Results

A total of 387 physicians were included. The most common cognitive biases were overconfidence (22.5%), confirmation (21.2%), availability (12.4%), and anchoring (11.4%). Of the error cases, the top five most common initial diagnoses were upper gastrointestinal disease (22.7%), trauma (14.7%), cardiovascular disease (10.9%), respiratory disease (7.5%), and primary headache (6.5%). The corresponding final diagnoses for these errors were intestinal obstruction or peritonitis (27.3%), overlooked traumas (47.4%), other cardiovascular diseases (66.7%), cardiovascular disease (41.4%), and stroke (80%), respectively.

Conclusions

A comparison of the initial and final diagnoses of cases with diagnostic errors shows that there were more cases with diagnostic errors caused by overlooking another disease in the same organ or a disease in a closely related organ.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00708-3.

Learning Interrupted: Educational Impact of Interruptions on Surgical Residents

OBJECTIVE

The complex workflow of surgical residents in the workplace-based learning environment makes interruptions an unavoidable aspect of clinical work. Interruptions have been shown to affect cognitive load, surgical performance, and medical error. The purpose of this study was to describe the effects of interruptions on surgical resident education.

DESIGN

Junior residents were observed by 2 trained observers using time-motion methodology between September 2018-August 2019. Interruptions were identified and coded retroactively based on predefined criteria. We captured key features of interruptions including frequency, duration, task interrupted, outcome, and learner perceived educational value.

SETTING

This study took place at London Health Sciences Centre in London, Ontario, Canada, a tertiary level academic health care center associated with the Schulich School of Medicine & Dentistry at Western University.

PARTICIPANTS

Junior residents on a General Surgery service were eligible for participation. Participation was voluntary. 8 residents were observed over 24 clinical periods.

RESULTS

A total of 278.2 hours of resident workflow were observed, and 229 interruptions were recorded. Interruptions account for 57.9 minutes/day of a surgical resident (SD = 60.7). Interruptions occur at a frequency of 0.82 interruptions/hour. Disruptive interruptions, that interfere with the continuation or completion of the original task, occur at a frequency of 0.11 interruptions/hour. Disruptive interruptions occurred at a higher frequency of 0.34 interruptions/hour during periods of feedback, coaching and informal teaching.

DISCUSSION

We observed that tasks of higher learner perceived educational value are often interrupted by tasks of lower learner perceived education value. Valuable educational experiences such as feedback, coaching and informal teaching are interrupted at a greater rate and experience disruptions at a disproportionate rate. We identified feedback, coaching and informal teaching as an education task vulnerable to disruptive interruptions that would benefit from interventions targeted toward preventing interruption. Suggested interventions include "formalizing" feedback, coaching and informal teaching.

Systematic review of interruptions in the emergency department work environment

OBJECTIVE

The purpose of this systematic review is to describe the operationalization of interruptions measurement and to synthesize the evidence on the causes and consequences of interruptions in the emergency department (ED) work environment.

METHODS

This systematic review of studies explores the causes and consequences of interruptions in the ED. Of 2836 abstract/titles screened, 137 full-text articles were reviewed, and 44 articles met inclusion criteria of measuring ED interruptions.

RESULTS

All articles reported primary data collection, and most were cohort studies (n = 30, 68%). Conceptual or operational definitions of interruptions were included in 27 articles. Direct observation was the most common approach. In half of the studies, quantitative measures of interruptions in the ED were descriptive only, without measurements of interruptions' consequences. Twenty-two studies evaluated consequences, including workload, delays, satisfaction, and errors. Overall, relationships between ED interruptions and their causes and consequences are primarily derived from direct observation within large academic hospitals using heterogeneous definitions. Collective strengths of interruptions research in the ED include structured methods of naturalistic observation and definitions of interruptions derived from concept analysis. Limitations are conflicting and complex evaluations of consequences attributed to interruptions, including the predominance of descriptive reports characterizing interruptions without direct measurements of consequences.

CONCLUSIONS

The use of standardized definitions and measurements in interruptions research could contribute to measuring the impact and influence of interruptions on clinicians' productivity and efficiency as well as patients' outcomes, and thus provide a basis for intervention research.

Paediatric resident workflow observations in a community-based hospital

Objective

Residency graduates need to demonstrate competence in prioritising safe patient care through appropriate management of multiple competing tasks and workflow interruptions. This pilot study aimed to characterise and correlate interruptions in paediatric resident workflow at an academically affiliated, community-based hospital.

Methods

One of three trained observers followed a resident physician during a convenience sample of 1–2 hour increments, either in the emergency department or on the wards, and recorded all observed activities and interruptions using an established time-motion tool. All participants completed a baseline Multi-Tasking Ability Test (MTAT) and pre-observation and post-observation surveys. Statistical approach included descriptive statistics, logistic regression, mixed model and ORs.

Results

18 paediatric residents were observed for 57.5 total hours (an average of 3.2 hours/resident) which included 329 interruptions, defined as any external event drawing the resident’s attention away from a primary task. Interruptions occurred an average of 5.9 times per resident per hour. Interrupted primary tasks were not resumed during the observation period 11% of the time. A personal/social-related interruption yielded an OR of 0.29 that the resident will return to a primary task within 5 min (p=0.007) when compared with patient-related verbal interruptions by the medical team. The MTAT Score indicated decreased efficiency for interns versus postgraduate year 2 residents (p=0.029). Residents’ MTAT Scores did not correlate with their time to return to a primary task following an interruption (p=0.11).

Conclusions

Paediatric resident workflow interruptions in the hospital were observed to occur frequently and should be expected. Personal/social interruptions were most likely to delay prompt return to a primary task. The MTAT Score, although improved between the first 2 years of residency training, did not correlate with efficient return to a primary task. Interruption management and mitigation strategies should be developed as part of a standardised residency task management curriculum.

Nonurgent Visits to the Pediatric Emergency Department before and during the First Peak of the COVID-19 Pandemic

Background

Nonurgent visits in pediatric Emergency Departments are a growing burden. In order to find predictors for those nonurgent visits, we performed a retrospective analysis of unscheduled visits at the Pediatric Emergency Department of the University Hospital of Bonn, Germany, in the year 2017. Additionally, we compared these findings to unscheduled visits during the first peak of the worldwide pandemic of the Coronavirus disease 2019, to see if there would be an effect on nonurgent pediatric Emergency Department attendances.

Methods

For our retrospective cohort study, we analyzed more than 5.000 visits at the pediatric Emergency Department of the University Hospital of Bonn, Germany, before and during the first peak of the ongoing worldwide pandemic of the Coronavirus disease 2019, particularly with regard to their urgency. Data included gender, age, zip code, urgency, and preexisting conditions.

Results

Our study shows that more than half of unscheduled pediatric Emergency Department visits (69%) at the University Hospital in Bonn are for nonurgent reasons, with short living distance being a factor to present children to a pediatric Emergency Department, even with minor complaints. During the first peak of the pandemic of the Coronavirus disease 2019, nonurgent visits decreased significantly, potentially due to hesitation to attend a pediatric Emergency Department with minor issues, fearing an infection with SARS-CoV-2 at the hospital.

Conclusion

Many people use pediatric Emergency Departments for nonemergency complaints. In order to address the reasons for nonurgent visits to pediatric Emergency Departments and to prevent parents from doing so, further studies and targeted education concepts for parents are needed.

Evaluation of the Time Spent by Anesthetist on Clinical Tasks in the Operating Room

Background

Changes in the health system in Western countries have increased the scope of the daily tasks assigned to physicians', anesthetists included. As already shown in other specialties, increased non-clinical burden reduces the clinical time spent with patients.

Methods

This was a multicenter, prospective, observational study conducted in 6 public and private hospitals in France. The primary endpoint was the evaluation by an external observer of the time spent per day (in minutes) by anesthetists on clinical tasks in the operating room. Secondary endpoints were the time spent per day (in minutes) on non-clinical organizational tasks and the number of task interruptions per hour of work.

Results

Between October 2017 and April 2018, 54 anesthetists from six hospitals (1 public university hospital, two public general hospitals and three private hospitals) were included. They were followed for 96 days corresponding to 550 hours of work. The proportion of overall clinical time was 62% (58% 95%CI [53; 63] for direct care. The proportion of organizational time was higher in public hospitals (11% in the university hospital (p < 0.001) and 4% in general hospitals (p < 0.01)) compared to private hospitals (1%). The number of task interruptions (1.5/h ± 1.4 in all hospitals) was 4 times higher in the university hospital (2.2/h ± 1.6) compared to private hospitals (0.5/h ± 0.3) (p < 0.05).

Conclusions

Most time in the operating room was spent on clinical care with a significant contrast between public and private hospitals for organizational time.

Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department

BACKGROUND

Emergency physicians (EP) are frequently interrupted to screen electrocardiograms (ECG) from Emergency Department (ED) patients undergoing triage. Our objective was to identify discrepancies between the computer ECG interpretation and the cardiologist ECG interpretation and if any patients with normal ECGs underwent emergent cardiac intervention. We hypothesized that computer-interpreted normal ECGs do not require immediate review by an EP.

METHODS

This was a retrospective study of adult (≥ 18 years old) ED patients with computer-interpreted normal ECGs. Laboratory, diagnostic testing and clinical outcomes were abstracted following accepted methodologic guidelines. The primary outcome was emergent cardiac catheterization (within four hours of ED arrival). All ECGs underwent final cardiologist interpretation. When cardiology interpretation differed from the computer (discrepant ECG interpretation), the difference was classified as potentially clinically significant or not clinically significant. Data was described with simple descriptive statistics.

MAIN FINDINGS

989 ECGs interpreted as normal by the computer were analyzed with a mean age of 50.4 ± 16.8 years (range 18-96 years) and 527 (53%) female. Discrepant ECG interpretations were identified in 184 cases including 124 (12.5%, 95% CI 10.4, 14.7%) not clinically significant and 60 (6.1%, 95% CI 4.6, 7.7%) potentially clinically significant. The 60 potentially clinically significant changes included: ST/T wave changes 45 (75%), T wave inversions 6 (10%), prolonged QT 3 (5%), and possible ischemia 10 (17%). Of these 60, 21 (35%) patients were admitted. Six patients had potassium levels >6.0 mEq/L, with one having a potentially clinically significant ECG change. No patient (0%, 95% CI 0, 0.3%) underwent immediate (within four hours) cardiac catherization whereas two underwent delayed cardiac interventions.

CONCLUSIONS

Cardiologists frequently disagree with a computer-interpreted normal ECG. Patients with computer-interpreted normal ECGs, however, rarely had significant ischemic events. A rare number of patients will have important cardiac outcomes regardless of the computer-generated normal ECG interpretation. Immediate EP review of the ECG, however, would not have changed these patients' ED courses.

Interruption of initial patient assessment in the emergency department and its effect on patient perception of care quality

BACKGROUND

Triage is a critical first step in appropriately caring for patients in the emergency department (ED). Patients' assumptions of the care they will receive can be established in triage. Interruptions to this process can disrupt patient flow, cause errors and lead to patient dissatisfaction.

OBJECTIVE

The purpose of this study was to determine how the frequency and duration of interruptions during triage are associated with errors, patient satisfaction and patient's perception of the care they received.

METHODS

Prospective, observational, cohort study conducted in the ED of a Level 1 trauma center. Interruptions were measured using time-and-motion observations of triage interviews performed by nurses and physicians. Patients were surveyed immediately after triage interviews were complete.

RESULTS

Surveys were completed for 178 observations. In total, 62.9% of the observations were interrupted between 1 and 5 times. While interruptions did not significantly influence patient satisfaction directly, interruptions positively influenced triage duration, which was negatively associated with patient satisfaction. Increased errors were associated with increasing frequency of triage interruptions. Triage interruptions were not associated with either patient satisfaction or perceived caregiver competence. Overall, the majority (76.6%) of patients were satisfied with their care; patient satisfaction was associated with the perceived competency of caregivers but was not associated with errors.

CONCLUSION

Interruptions are associated with increased errors and delays in patient care. Although increased triage duration adversely affected patient satisfaction, patients' perceptions were not influenced by interruptions. While patient satisfaction is essential, a lack of association between patient satisfaction and errors suggests that using patient satisfaction as a measure of care quality may omit important safety information.

Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments

OBJECTIVE

Diagnostic errors are major contributors to preventable patient harm. We validated the use of an electronic health record (EHR)-based trigger (e-trigger) to measure missed opportunities in stroke diagnosis in emergency departments (EDs).

METHODS

Using two frameworks, the Safer Dx Trigger Tools Framework and the Symptom-disease Pair Analysis of Diagnostic Error Framework, we applied a symptom-disease pair-based e-trigger to identify patients hospitalized for stroke who, in the preceding 30 days, were discharged from the ED with benign headache or dizziness diagnoses. The algorithm was applied to Veteran Affairs National Corporate Data Warehouse on patients seen between 1/1/2016 and 12/31/2017. Trained reviewers evaluated medical records for presence/absence of missed opportunities in stroke diagnosis and stroke-related red-flags, risk factors, neurological examination, and clinical interventions. Reviewers also estimated quality of clinical documentation at the index ED visit.

RESULTS

We applied the e-trigger to 7,752,326 unique patients and identified 46,931 stroke-related admissions, of which 398 records were flagged as trigger-positive and reviewed. Of these, 124 had missed opportunities (positive predictive value for "missed" = 31.2%), 93 (23.4%) had no missed opportunity (non-missed), 162 (40.7%) were miscoded, and 19 (4.7%) were inconclusive. Reviewer agreement was high (87.3%, Cohen's kappa = 0.81). Compared to the non-missed group, the missed group had more stroke risk factors (mean 3.2 vs 2.6), red flags (mean 0.5 vs 0.2), and a higher rate of inadequate documentation (66.9% vs 28.0%).

CONCLUSION

In a large national EHR repository, a symptom-disease pair-based e-trigger identified missed diagnoses of stroke with a modest positive predictive value, underscoring the need for chart review validation procedures to identify diagnostic errors in large data sets.

Degree of interruptions experienced by emergency department nurses and interruption related factors

AIMS

This study examined the degree of interruptions experienced by emergency department nurses and related factors.

METHODS

This study is a descriptive survey using standardized observation tools. A total of 23 nurses working in an emergency department participated in this study. Using a stopwatch over 120 h, the degree of interruptions was investigated by measuring start and end times of tasks and interruptions. Factors related to interruptions were classified as communication, telephone calls, medical device alarms, changes in patient condition, and other factors.

RESULTS

The frequency of interruptions in the emergency department was 6.4 times per hour, and its percentage was 9.1%. The time required for actual nursing tasks of "counseling and education," "safety," and "patient nursing management and information management" were increased significantly due to interruptions. A primary factor in interruptions was communication with patients, families, and nurses. The longest duration and the highest frequency of interruptions occurred during medication tasks.

CONCLUSIONS

Communication with patients, families, and nurses was the highest factor related to interruptions. Nurses may cause interruptions and be subjected to interruptions simultaneously. Therefore, nurses in the emergency department should work with caution not to cause interruptions.

Multitasking in postanesthesia care unit following nurse interruptions, an analysis of the causes and consequences using classification tree: an observational prospective study

BACKGROUND

Postanesthesia Care Unit (PACU) is an environment associated with an important workload which is susceptible to lead to task interruption (TI), leading to task-switching or concurrent multitasking. The objective of the study was to determine the predictors of the reaction of the nurses facing TI and assess those who lead to an alteration of the initial task.

METHODS

We conducted a prospective observational study into the PACU of a university hospital during February 2017. Among 18 nurses, a selected one was observed each day, documenting for each TI the reaction of the nurse (task switching or concurrent multitasking), and the characteristics associated with the TI. We performed classification tree analyses using C5.0 algorithm in order to select the main predictors of the type of multitasking performed and the alteration of the initial task.

RESULTS

We observed 1119 TI during 132 hours (8.5 TI/hour). The main reaction was concurrent multitasking (805 TI, 72%). The short duration of the task interruption (one minute or less) was the most important predictor leading to concurrent multitasking. Other predictors of response to TI were the identity of the task interrupter and the number of nurses present. Regarding the consequences of the task switching, long interruption (more than five minutes) was the most important predictor of the alteration of the initial task.

CONCLUSIONS

By analysing the predictors of the type of multitasking in front of TI, we propose a novel approach to understanding TI, offering new perspective for prevention strategies.

Identifying Strategies for the Management of Interruptions for Novice Triage Nurses Using an Online Modified Delphi Method

PURPOSE

To use the Delphi Method to identify strategies used by triage nurses to effectively manage interruptions.

DESIGN

This study was based on the concepts of Benner's Novice to Expert Model. An online, modified Delphi approach was used to engage triage, education, and operational management experts in generating consensus recommendations on successful strategies to address triage interruptions in the emergency department.

METHODS AND ANALYSIS

A panel of nine triage, education, and operational management experts were selected based on their publication and presentation history. This panel participated in three Delphi rounds, providing individual responses during each round. All responses were entered into a RedCap database, which allowed research team members to synthesize the results and return summaries to the participants. Final consensus was reached among this panel regarding recommendations for successful strategies to address triage interruptions that can be encompassed in a training module. The experts were then asked to identify the best instructional modality for teaching each of the interruption management strategies.

FINDINGS

Eight strategies to mitigate the impact of interruptions were identified: (a) ensure nurses understand impact of interruptions; (b) ensure nurses understand consequences of interruptions on cognitive demands of healthcare workers that could influence behavior and lead to errors; (c) apologize to current patient before tending to interruption and give expectation of when you will return; (d) triage the interruption and decide to (i) ignore interruption, (ii) acknowledge, but delay servicing, interruption, or (iii) acknowledge and service interruption, delaying completion of interrupted task; (e) identify urgent communication as anything clinically significant that impacts the patient immediately or requires immediate intervention; (f) use focused questions to clarify whether interruption can wait; (g) redirect nonpriority interruptions; and (h) finish safety-critical task or tasks near completion before tending to an interruption. The Delphi participants recommended the best teaching modality was simulation for six of the strategies.

CONCLUSIONS

Participants agreed that there are strategies that can be taught to novice triage nurses to mitigate the impact of interruptions. The experts in operations management, emergency nursing, and education agree that creating simulations to teach each of these strategies is an effective way to educate nurses.

CLINICAL RELEVANCE

Interruptions impact the quality of care provided to patients. Training nurses to prevent interruptions and mitigate the impact of interruptions when they occur has the potential to improve patient outcomes.

Nursing interruptions in emergency room in China: An observational study

AIM

To analyse the frequency and core elements of nursing work interruptions in Chinese emergency nursing settings.

BACKGROUND

Little is known about nursing interruptions, which affect the quality of services in Chinese emergency nursing setting.

METHOD(S)

A cross-sectional observational study was conducted in three units of an emergency department in a Chinese tertiary hospital. Participants comprised 60 nurses. Data were collected using a questionnaire developed by the researchers specifically for this study.

RESULTS

In total, 25,965 min of work was observed and 2333 interruptions were identified. Most interruptions were from patients, their families and nurses. Therapeutic nursing and patient observation and documentation were the most frequently interrupted procedures. Most interruptions were negative, and a majority of the nurses immediately responded to interruptions. Significant differences existed in the overall distribution of the core elements among the three nursing units.

CONCLUSIONS

The frequency of emergency nursing interruptions was moderate. Most interruptions tend to lead to negative treatment outcomes for patients.

IMPLICATIONS FOR NURSING MANAGEMENT

Emergency nursing managers should recognize the importance of interruptions, understand work situations better and develop ways to reduce the incidence of interruptions. Thus, nursing risks can be avoided by reducing the adverse outcomes caused by work interruptions.

Physicians' and nurses' work time allocation and workflow interruptions in emergency departments: a comparative time-motion study across two countries

BACKGROUND

Globally, emergency department (ED) work is fast-paced and subject to interruptions, placing high coordination and communication demands on staff. Our study aimed to compare ED staffs' work time allocation and interruption rates across professional roles and two national settings.

METHODS

We conducted a time-motion study with standardised expert observations of ED physicians and nurses in Germany and the USA. Observers coded ED staffs' activities and workflow interruptions. General and generalised linear models were used to examine differences in activities and interruption rates between countries and ED professions.

RESULTS

28 observations were conducted in the USA and 30 in Germany. Overall, the largest portion of time spent by ED staff in both settings was in documentation (22.0%). Physicians spent more time in verbal interaction with patients (9.9% vs 5.2% in nurses; p=0.006), in documentation (29.4% vs 15.6%; p<0.001) and other professional activities (13.0% vs 4.8%; p=0.002). Nurses allocated significantly more time to therapeutic (22.3% vs 6.0% in physicians; p<0.001) and organisational activities (20.4% vs 9.5%; p<0.001). Overall mean interruption rate per hour was 10.16 (US ED: 8.15, German ED: 12.04; p<0.001). American physicians and German nurses were most often disrupted by colleagues of the same profession (country: B=-.27, p=0.027; profession: B=0.35, p=0.006). German ED staff were interrupted more often by patients (B=-.78, p=0.001) and other sources (B=-.76, p<0.001) than American ED staff.

DISCUSSION

Our findings corroborate that professional roles largely determine time allocation to specific activities. However, interruption rates indicate differences between countries, suggesting the need for context-specific solutions to work stressors.

Improving Team-Based Decision Making Using Data Analytics and Informatics: Protocol for a Collaborative Decision Support Design

Background

According to the September 2015 Institute of Medicine report, Improving Diagnosis in Health Care, each of us is likely to experience one diagnostic error in our lifetime, often with devastating consequences. Traditionally, diagnostic decision making has been the sole responsibility of an individual clinician. However, diagnosis involves an interaction among interprofessional team members with different training, skills, cultures, knowledge, and backgrounds. Moreover, diagnostic error is prevalent in the interruption-prone environment, such as the emergency department, where the loss of information may hinder a correct diagnosis.

Objective

The overall purpose of this protocol is to improve team-based diagnostic decision making by focusing on data analytics and informatics tools that improve collective information management.

Methods

To achieve this goal, we will identify the factors contributing to failures in team-based diagnostic decision making (aim 1), understand the barriers of using current health information technology tools for team collaboration (aim 2), and develop and evaluate a collaborative decision-making prototype that can improve team-based diagnostic decision making (aim 3).

Results

Between 2019 to 2020, we are collecting data for this study. The results are anticipated to be published between 2020 and 2021.

Conclusions

The results from this study can shed light on improving diagnostic decision making by incorporating diagnostics rationale from team members. We believe a positive direction to move forward in solving diagnostic errors is by incorporating all team members, and using informatics.

International Registered Report Identifier (IRRID)

DERR1-10.2196/16047

A cluster randomised controlled feasibility study of nurse-initiated behavioural strategies to manage interruptions during medication administration

OBJECTIVES

To examine the feasibility of a behavioural e-learning intervention to support nurses to manage interruptions during medication administration.

DESIGN

A cluster randomised feasibility trial.

SETTING

The cluster trial included four intervention and four control wards randomly selected across four metropolitan hospitals in Sydney, Australia.

PARTICIPANTS

We observed 806 (402 pre-intervention and 404 post-intervention) medication events, where nurses prepared and administered medications to patients within the cluster wards.

MAIN OUTCOME MEASURES

The primary outcome measured was the observed number of interruptions occurring during administration, with secondary outcomes being the number of clinical errors and procedural failures. Changes in the use of behavioural strategies to manage interruptions, targeted by the e-learning intervention, were also assessed.

RESULTS

No significant differences were found in the number of interruptions (P = 0.82), procedural failures (P = 0.19) or clinical errors per 100 medications (P = 0.32), between the intervention and control wards. Differences in the use of specific behavioural strategies (engagement and multitasking) were found in the intervention wards.

CONCLUSION

This behavioural e-learning intervention has not been found to significantly reduce interruptions, however, changes in the use of strategies did occur. Careful selection of clinical settings where there is a high number of predictable interruptions is recommended for further research into the impact of the behavioural e-learning intervention. An increase in the intensity of this intervention is recommended with training undertaken away from the clinical setting. Further research on additional consumer-sensitive interventions is urgently needed.

Refinement, reliability and validity of the Time Capture Tool (TimeCaT) using the Omaha System to support data capture for time motion studies

AIM

To refine and assess the inter-rater reliability and content validity of the embedded interface of nursing/midwifery activities in the Time Capture Tool (TimeCaT) using an interface terminology, the Omaha System.

METHODS

This methodological study was conducted in two Family Health Centers (FHCs) in Turkey with a total of 13 nurses and midwives. In phase one, five nurses/midwives in a FHC were observed for a total of 80 hr, and 84 nursing/midwifery activities were generated and validated with 15 content experts. In phase two, the nursing/midwifery activities were mapped to the Omaha System and inter-rater reliability of the mapping was assessed. The mapping was validated with seven content experts. The nursing/midwifery activities were embedded in the interface of the TimeCaT. In phase three, the embedded interface of the TimeCaT was evaluated while observing eight nurses and midwives in the other FHC.

RESULTS

The scale-level content validity index was 0.98 for the generated activities in phase one and 0.96 for the mapped activities in phase two. Kappa statistics for inter-rater reliability was 0.88 for Omaha System problems, 0.83 for categories and 0.83 for targets. The nursing/midwifery activities were adequately mapped to the Omaha System. The embedded interface of the TimeCaT has acceptable inter-rater reliability and content validity values for using in the Turkish FHC context.

CONCLUSION

The study results confirm that the TimeCaT using the Omaha System is a valid and reliable tool to measure nursing/midwifery workflow in FHC settings.

A Novel Algorithm for Improving the Diagnostic Accuracy of Prehospital ST-Elevation Myocardial Infarction

INTRODUCTION

ST-segment elevation myocardial infarction (STEMI) is a time-sensitive entity that has been shown to benefit from prehospital diagnosis by electrocardiogram (ECG). Current computer algorithms with binary decision making are not accurate enough to be relied on for cardiac catheterization lab (CCL) activation.

HYPOTHESIS

An algorithmic approach is proposed to stratify binary STEMI computerized ECG interpretations into low, intermediate, and high STEMI probability tiers.

METHODS

Based on previous literature, a four-criteria algorithm was developed to rule out/in common causes of prehospital STEMI false-positive computer interpretations: heart rate, QRS width, ST elevation criteria, and artifact. Prehospital STEMI cases were prospectively collected at a single academic center in Salt Lake City, Utah (USA) from May 2012 through October 2013. The prehospital ECGs were applied to the algorithm and compared against activation of the CCL by an emergency department (ED) physician as the outcome of interest. In addition to calculating test characteristics, linear regression was used to look for an association between number of criteria used and accuracy, and logistic regression was used to test if any single criterion performed better than another.

RESULTS

There were 63 ECGs available for review, 39 high probability and 24 intermediate probability. The high probability STEMI tier had excellent test characteristics for ruling in STEMI when all four criteria were used, specificity 1.00 (95% CI, 0.59-1.00), positive predictive value 1.00 (0.91-1.00). Linear regression showed a strong correlation demonstrating that false-positives increased as fewer criteria were used (adjusted r-square 0.51; P <.01). Logistic regression showed no significant predictive value for any one criterion over another (P = .80). Limiting physician overread to the intermediate tier only would reduce the number of ECGs requiring physician overread by a factor of 0.62 (95% CI, 0.48-0.75; P <.01).

CONCLUSION

Prehospital STEMI ECGs can be accurately stratified to high, intermediate, and low probabilities for STEMI using the four criteria. While additional study is required, using this tiered algorithmic approach in prehospital ECGs could lead to changes in CCL activation and decreased requirements for physician overread. This may have significant clinical and quality implications.

Usability Evaluation of Visual Representation Formats for Emergency Department Records

BACKGROUND

Integration of electronic information is a challenge for multitasking emergency providers, with implications for patient safety. Visual representations can assist sense-making of complex data sets; however, benefit and acceptability in emergency care is unproven.

OBJECTIVES

This article evaluates visually focused alternatives to lists or tabular formats, to better understand possible usability in Emergency Department Information System (EDIS).

METHODS

A counterbalanced, repeated-measures experiment, satisfaction surveys, and narrative content analysis was conducted remotely by Web platform. Participants were 37 American emergency physicians; they completed 16 clinical cases comparing 4 visual designs to the control formats from a commercially available EDIS. They then evaluated two additional chart overview representations without controls.

RESULTS

Visual designs provided benefit in several areas compared to controls. Task correctness (90% to 76%; p = 0.003) and completion time (median: 49-74 seconds; p < 0.001) were superior for a medication history timeline with class and schedule highlighting. Completion time (median: 45-60 seconds; p = 0.03) was superior for a past medical history design, using pertinent diagnosis codes in highlighting rules. Less mental effort was reported for visual allergy (p = 0.04), past medical history (p < 0.001), and medication timeline (p < 0.001) designs. Most of the participants agreed with statements of likeability, preference, and benefit for visual designs; nonetheless, contrary opinions were seen, and more complex designs were viewed less favorably.

CONCLUSION

Physician performance with visual representations of clinical data can in some cases exceed standard formats, even in absence of training. Highlighting of priority clinical categories was rated easier-to-use on average than unhighlighted controls. Perceived complexity of timeline representations can limit desirability for a subset of users, despite potential benefit.

The Use of Smart Devices by Care Providers in Emergency Departments: Cross-Sectional Survey Design

BACKGROUND

The use of smart devices (SDs) by health care providers in care settings is a common practice nowadays. Such use includes apps related to patient care and often extends to personal calls and applications with frequent prompts and interruptions. These prompts and interruptions enhance the risk of distractions caused by SDs and raise concerns about service quality and patient safety. Such concerns are exacerbated in complex care settings such as the emergency department (ED).

OBJECTIVE

The objective of this study was to measure the frequency and patterns of SD use among health care providers in the ED of a large academic health center in Lebanon. The perceived consequences of care providers using SDs on provider-to-provider communication and the care quality of patients in the ED were assessed. Additionally, factors associated with the use of SDs and the approval for regulating such use were also investigated.

METHODS

The study was carried out at the ED of an academic health center with the highest volume of patient visits in Lebanon. The data were collected using a cross-sectional electronic survey sent to all ED health care providers (N=236). The target population included core ED faculty members, attending physicians, residents, medical students, and the nursing care providers. The regression model developed in this study was used to find predictors of medical errors in the ED because of the use of SDs.

RESULTS

Half of the target population responded to the questionnaire. A total of 83 of 97 respondents (86%) used one or more medical applications on their SDs. 71 out of 87 respondents (82%) believed that using SDs in the ED improved the coordination among the care team, and 71 out of 90 (79%) respondents believed that it was beneficial to patient care. In addition, 37 out of 90 respondents (41%) acknowledged that they were distracted when using their SDs for nonwork purposes. 51 out of 93 respondents (55%) witnessed a colleague committing a near miss or an error owing to the SD-caused distractions. Regression analysis revealed that age (P=.04) and missing information owing to the use of SDs (P=.02) were major predictors of committing an error in the ED. Interestingly, more than 40% of the respondents were significantly addicted to using SDs and more than one-third felt the need to cut down their use.

CONCLUSIONS

The findings of this study make it imperative to ensure the safety and wellbeing of patients, especially in high intensity, high volume departments like the ED. Irrespective of the positive role SDs play in the health care process, the negative effects of their use mandate proper regulation, in particular, an ethical mandate that takes into consideration the significant consequences that the use of SDs may have on care processes and outcomes.

Effectiveness of interventions to reduce occupational stress among emergency department staff: a systematic review protocol

REVIEW QUESTION

The aim of the review is to synthesize the best available evidence on interventions targeting occupational stress and burnout among emergency department (ED) staff. The specific review questions are.

Push Notifications Reduce Emergency Department Response Times to Prehospital ST-segment Elevation Myocardial Infarction

INTRODUCTION

Prehospital acquisition of electrocardiograms (ECG) has been consistently associated with reduced door-to-balloon times in the treatment of ST-segment myocardial infarction (STEMI). There is little evidence establishing best hospital practices once the ECG has been received by the emergency department (ED). This study evaluates the use of a push notification system to reduce delays in cardiac catheterization lab (CCL) activation for prehospital STEMI.

METHODS

In this prospective before-and-after study, we collected prehospital ECGs with computer interpretation of STEMI from May 2012 to October 2013. Push notifications were implemented June 1, 2013. During the study period, we collected timestamps of when the prehospital ECG was received (email timestamp of receiving account), CCL team activation (timestamp in paging system), and patient arrival (timestamp in ED tracking board). When prehospital ECGs were received in the ED, an audible alert was played via the Vocera WiFi communication system, notifying nursing staff that an ECG was available for physician interpretation. We compared the time from receiving the ECG to activation of the CCL before and after the audible notification was implemented.

RESULTS

Of the 56 cases received, we included 45 in our analysis (20 cases with pre-arrival CCL activation and 25 with post-arrival activation). For the pre-arrival group, the interval from ECG received to CCL activation prior to implementation was 9.1 minutes with a standard deviation (SD) of 5.7 minutes. After implementation, the interval was reduced to 3.33 minutes with a SD of 1.63 minutes. Delay was decreased by 5.8 minutes (p < 0.01). Post-implementation activation times were more consistent, demonstrated by a decrease in SD from 5.75 to 1.63 min (p < 0.01). For patients with CCL activation after arrival, there was no significant change in mean delay after implementation.

CONCLUSION

In this small, single-center observational study, we demonstrated that the use of push notifications to ED staff alerting that a prehospital STEMI ECG was received correlated with a small reduction in, and increased consistency of, ED CCL activation.

Cognitive error in an academic emergency department

Background

Medical error is a leading cause of death nationwide. While systems issues have been closely investigated as a contributor to error, little is known about the cognitive factors that contribute to diagnostic error in an emergency department (ED) environment.

Methods

Eight months of patient revisits within 72 h where patients were admitted on their second visit were examined. Fifty-two cases of confirmed error were identified and classified using a modified version of the Australian Patient Safety Foundation classification system for medical errors by a group of trained physicians.

Results

Faulty information processing was the most frequently identified category of error (45% of cases), followed by faulty verification (31%). Faulty knowledge (6%) and faulty information gathering (18%) occurred relatively infrequently. “Misjudging the salience of a finding” and “premature closure” were the individual errors that occurred most frequently (13%).

Conclusions

Despite the complex nature of diagnostic reasoning, cognitive errors of information processing appear to occur at higher rates than other errors, and in a similar pattern to an internal medicine service despite a different clinical environment. Further research is needed to elucidate why these errors occur and how to mitigate them.

Effects of Interruptions on Triage Process in Emergency Department: A Prospective, Observational Study

For 130 million people seeking emergency treatment in the United States, incomplete or inaccurate triage examination can result in delays, which could compromise patient outcomes. The purpose of this study was to identify triage interruptions and determine how interruptions affect the triage process. A significant difference was seen in triage duration between interrupted and uninterrupted interviews. Understanding the impact of interruptions on patient outcomes will allow nurses and other health care providers to develop interventions to mitigate the impact.