Juliana J. Brixey

Interruptions in a Level One Trauma Center: A Case Study

BACKGROUND The emergency department has been characterized as interrupt-driven. Government agencies and patient safety organizations recognize that interruptions contribute to medical errors. The purpose of this study was to observe, record, and contextualize activities and interruptions experienced by physicians and Registered Nurses (RNs) working in a Level One Trauma Center. METHODS DESIGN A case study that relied on an ethnographic study design using the shadowing method. SUBJECTS A convenience sample of physicians and RNs, each with at least 6 months of experience in the Emergency Department (ED), were asked to participate. In these kinds of detailed qualitative investigations, it is quite common to have a small sample size. Ethical approval: Approval was obtained from institutional ethic committees prior to initiating the study. Community consent was obtained from the ED staff through in-service education. SETTING All observations were made in the trauma section of the ED of a tertiary teaching hospital. The hospital is situated in a major medical center in the Gulf Coast region of the United States of America (USA). FINDINGS Five attending ED physicians were observed for a total of 29h, 31min. Eight RNs were shadowed for a total of 40 h, 9min. Interruptions and activities were categorized using the Hybrid Method to Categorize Interruptions and Activities (HyMCIA). Registered Nurses received slightly more interruptions per hour than physicians. People, pagers, and telephones were identified as mediums through which interruptions were delivered. The physical environment was found to contribute to interruptions in workflow because of physical design and when supplies were not available. Physicians and RNs usually returned to the original, interrupted activity more often than leaving the activity unfinished. CONCLUSION This research provides an enhanced understanding of interruptions in workflow in the ED, the identification of work constraints, and the need to develop interventions to manage interruptions. It is crucial that interruptions be delivered in such a way that there is minimal negative impact on performance. The significance and importance of the interruption must always be weighed against the negative impact that it has on smooth, efficient workflow.

A concept analysis of the phenomenon interruption.

An interruption was found to have no consistent definition in either healthcare or nonhealthcare literature. Walker and Avants 8-step method of concept analysis was used to clarify, define, and develop a conceptual model of interruption. The analysis led to the identification of 5 defining attributes that include (1) a human experience; (2) an intrusion of a secondary, unplanned, and unexpected task; (3) discontinuity; (4) externally or internally initiated; and (5) situated within a context. Use of the defining attributes will be extended to form a category of interruption within a taxonomy of activity.

Towards a hybrid method to categorize interruptions and activities in healthcare

OBJECTIVE Interruptions are known to have a negative impact on activity performance. Understanding how an interruption contributes to human error is limited because there is not a standard method for analyzing and classifying interruptions. Qualitative data are typically analyzed by either a deductive or an inductive method. Both methods have limitations. In this paper, a hybrid method was developed that integrates deductive and inductive methods for the categorization of activities and interruptions recorded during an ethnographic study of physicians and registered nurses in a Level One Trauma Center. Understanding the effects of interruptions is important for designing and evaluating informatics tools in particular as well as improving healthcare quality and patient safety in general. METHOD The hybrid method was developed using a deductive a priori classification framework with the provision of adding new categories discovered inductively in the data. The inductive process utilized line-by-line coding and constant comparison as stated in Grounded Theory. RESULTS The categories of activities and interruptions were organized into a three-tiered hierarchy of activity. Validity and reliability of the categories were tested by categorizing a medical error case external to the study. No new categories of interruptions were identified during analysis of the medical error case. CONCLUSIONS Findings from this study provide evidence that the hybrid model of categorization is more complete than either a deductive or an inductive method alone. The hybrid method developed in this study provides the methodical support for understanding, analyzing, and managing interruptions and workflow.

The roles of MDs and RNs as initiators and recipients of interruptions in workflow

BACKGROUND Previous research studies have focused on the recipients of interruptions because of the negative impact interruptions have on task performance. It is equally important to understand the initiators of interruptions to help design strategies to lessen the number of interruptions and the possible negatives consequences. The purpose of this study was to examine MDs and RNs as initiators and recipients of interruptions. METHODS This was an instrumental case study using the shadowing method. A convenience sample of five attending trauma MDs and eight RNs were observed during the 07:00-15:00 and 15:00-21:00 shifts in the trauma section of a level one trauma center. RESULT Seventy hours of observations were recorded. Initiator and recipient of an interruption emerged as major roles during categorization of the notes. Medical doctors and RNs were found to be the recipient of an interruption more frequently than the initiator. Findings from this study indicate that MDs and RNs initiate interruptions most often through face-to-face interactions and use of the telephone. CONCLUSIONS A role-based taxonomy of interruptions was derived from the recorded notes. Strategies to successfully manage interruptions must consider both the role of initiator as well as the recipient when an interruption occurs. It is suggested that the role-based taxonomy presented in this paper be used to classify interruptions in future studies.

Contributing factors to errors in Swedish emergency departments

OBJECTIVE The Emergency Department (ED) is a complex and dynamic environment, often resulting in a somewhat uncontrolled and unpredictable workload. Contributing factors to errors in health care and in the ED are largely related to communication breakdowns. Moreover, the ED work environment is predisposed to multitasking, overcrowding and interruptions. These factors are assumed to have a negative impact on patient safety. Reported errors from care providers are mainly related to diagnostic procedures in Swedish EDs. However, there is a lack of knowledge and national oversight regarding contributing factors. The aim of this study was therefore to describe contributing factors in regards to errors occurring in Swedish EDs. METHOD Descriptive design based on registry data from the Lex Maria database of the Swedish National Board of Health and Welfare. RESULTS The results indicate that factors contributing to errors in Swedish EDs are multifactorial in nature. The most common contributing factor was human error followed by factors in the local ED environment and teamwork failure. CONCLUSION Factors contributing to ED errors were multifactorial and included both organizational and teamwork failure in which human error was implicated. To reduce errors, further research is needed to develop methods that disclose latent working conditions such as high workload and interruptions. Patient safety research needs to include understanding of human behaviour in complex organizational systems and the impact of working conditions on patient safety and quality of care.

Proposing a taxonomy and model of interruption

Interruptions not only decrease performance but can also cause human errors that lead to catastrophic events. Interruptions in high-risk industries such as aviation and nuclear power plants have been studied extensively because of catastrophic events such as power plant shut downs and plane crashes. In contrast, healthcare has a limited understanding of interruption despite the frequent occurrence of medical errors; often leading to adverse events and mortality. We reviewed and integrated previously published literature in healthcare to propose a taxonomy and model of interruptions. This taxonomy will help us categorize and understand interruptions in healthcare. The model depicts interrupted task performance and possible error states when resuming an interrupted task.

Clinical Workflow Analysis, Process Redesign, and Quality Improvement

Healthcare workflow is driven by individual, organizational, and societal factors. The resulting complexity and high variability make it challenging to examine workflow in healthcare delivery settings. In this chapter, the authors introduce relevant theories, frameworks, principles, tools, and techniques to guide both (a) workflow examination and (b) systematic organizational interventions for workflow redesign. These theories, frameworks, principles, tools, and techniques can be applied to diverse settings to improve the quality and safety of healthcare delivery.

Legibility of a volumetric infusion pump in a shock trauma ICU

BACKGROUND Reports submitted to the Federal Food and Drug Administration (FDA) indicate that legibility of infusion pump interfaces contributes to medication errors (for example, patients have been seriously injured when nurses overinfused them after reading the number 7 as a 1). Health care has experienced an influx of medical devices with small-screen interfaces, generically described as small-screen devices. Legibility is widely acknowledged as a necessary aspect of safe operation of medical devices. Contextual analysis was used to observe conditions affecting the legibility of the screen interface of a dual-channel infusion volumetric infusion pump in a shock trauma intensive care unit (STICU). METHODS Observations were made of registered nurses and physicians using the infusion pumps during a four-hour period. RESULTS Results from the observations indicated that there was reduced legibility of the infusion pump screen interface because of an inherently subdued light situation, reduced screen contrast, and the small font size of the lettering. DISCUSSION It was clear from the beginning of the observations that the screen of the infusion pump had limited legibility. In some instances, nurses attached handmade tape labels to the infusion pump to enhance and supplement the small screen. The pump was often positioned facing away from the nurses, who then had to reposition it to view the screen, contributing to interruptions in work flow and creating a potential safety hazard. A variety of strategies are recommended to ensure legibility of infusion pump interfaces and of medical-device labels. CONCLUSIONS A more complete environmental approach is needed to determine the legibility and usefulness of microdisplay and small-screen devices in health care.

Second life: not your conventional simulation.

Second Life is a massive, multiuser, virtual environment. The University of Kansas School of Nursing has introduced SL into the health informatics curriculum as a virtual environment for students and faculty to interact and communicate. Students have successfully completed course activities in SL. Informatics faculty continue to develop simulations in SL.

A systematic review of prehospital telehealth utilization

Objective There has been moderate evidence of telehealth utilization in the field of emergency medicine, but less is known about telehealth in prehospital emergency medical services (EMS). The objective of this study is to explore the extent, focus, and utilization of telehealth for prehospital emergency care through the analysis of published research. Methods The authors conducted a systematic literature review by extracting data from multiple research databases (including MEDLINE/PubMed, CINAHL Complete, and Google Scholar) published since 2000. We used consistent key search terms to identify clinical interventions and feasibility studies involving telehealth and EMS, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results We identified 68 articles focused specifically on telehealth interventions in prehospital care. The majority (54%) of the studies involved stroke and acute cardiovascular care, while only 7% of these (4) focused on telehealth for primary care. The two most common delivery methods were real-time video-conferencing capabilities (38%) and store and forward (25%); and this variation was based upon the clinical focus. There has been a significant and positive trend towards greater telehealth utilization. European telehealth programs were most common (51% of the studies), while 38% were from the United States. Discussion and Conclusions Despite positive trends, telehealth utilization in prehospital emergency care is fairly limited given the sheer number of EMS agencies worldwide. The results of this study suggest there are significant opportunities for wider diffusion in prehospital care. Future work should examine barriers and incentives for telehealth adoption in EMS.