Katherine L. Forsyth

Physician Interruptions and Workload during Emergency Department Shifts

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

Shortcut assessment: Can residents’ operative performance be determined in the first five minutes of an operative task?

Background: The aim was to validate the potential use of a single, early procedure, operative task as a predictive metric for overall performance. The authors hypothesized that a shortcut psychomotor assessment would be as informative as a total procedural psychomotor assessment when evaluating laparoscopic ventral hernia repair performance on a simulator. Methods: Using electromagnetic sensors, hand motion data were collected from 38 surgery residents during a simulated laparoscopic ventral hernia repair procedure. Three time‐based phases of the procedure were defined: Early Phase (start time through completion of first anchoring suture), Mid Phase (start time through completion of second anchoring suture), and Total Operative Time. Correlations were calculated comparing time and motion metrics for each phase with the final laparoscopic ventral hernia repair score. Results: Analyses revealed that execution time and motion, for the first anchoring suture, predicted procedural outcomes. Greater execution times and path lengths correlated to lesser laparoscopic ventral hernia repair scores (r=‐0.56, P=.0008 and r=‐0.51, P=.0025, respectively). Greater bimanual dexterity measures correlated to Greater LVH repair scores (r=+0.47, P=.0058). Conclusions: This study provides validity evidence for use of a single, early operative task as a shortcut assessment to predict resident performance during a simulated laparoscopic ventral hernia repair procedure. With the continued development and decreasing costs of motion technology, faculty should be well‐versed in the use of motion metrics for performance measurements. The results strongly support the use of dexterity and economy of motion (path length+execution time) metrics as early predictors of operative performance.

Methodology for co-creating provider-centered interventions for mitigating interruptions in the emergency department

The high uncertainty of the emergency department (ED) and intermittent time-critical activities creates unpredictable staff workloads. Frequent interruptions are inherent to this acute care work environment adding to the demands placed on clinicians. Implementing sustainable interventions to mitigate interruptions has been a challenge. This study examined interruptions in the emergency department and provides a methodology for co-creating interventions to eliminate and/or manage interruptions impact on the care process. Observers collected and categorized interruptions using a validated tablet PC-based tool during clinicians’ entire shifts. Focus groups were used to develop and select provider-centered interventions. A total of 7889 interruptions were identified across 91 shifts. A total of 24 interventions were selected for potential implementation. The interventions were related to (1) protocol, procedures and policy, (2) information sharing, (3) devices and (4) role clarity. Developing sustainable solutions to interruptions has the potential to reduce patients’ vulnerability.

Perceived Workload and an Automated Workload Alert System: A Comparison in the Emergency Department

The aim of this study was twofold—(1) to compare the current ED staffing workload alert system to clinicians’ perceptions of workload in the ED, and (2) to examine the potential impact of a multi-faceted, systems-level intervention on clinicians’ perceptions of workload. Constant flow of patients into the Emergency Departments (ED) regularly increases the workload of clinicians and can compromise the quality of care delivery and patient safety. An automatic staffing workload alert system was created and implemented in response to an observed shift in patient volume to the overnight hours at one academic quaternary care center. Surveys addressing workload and interruptions were administered to ED clinicians, pre-and post-intervention implementation. Output from the staffing workload alert system was recorded for each clinician shift. Clinicians’ perceptions of workload were able to predict swing shift activations, χ2(6) = 14.14, p = 0.028. Only the performance subscale significantly correlated with swing shift activations, p=0.006. A Kruskal-Wallis H test found perceived interruptions changed following systems-level changes, χ2(1) = 7.195, p = 0.007. Utilizing subjective measure of clinicians’ workload validated an objective, automated staffing workload alert system that determined if swing shift activations are necessary.

A Pilot Study Characterising Interruptions Experienced By Emergency Medicine Residents

Interruptions in the emergency department (ED) have been studied across multiple clinical roles, with little investigation into how residents experience interruptions. Therefore this pilot study aimed to characterize interruptions experienced by emergency medicine (EM) residents at various post-graduate year (PGY) levels. Observers shadowed ED residents across entire shifts and logged interruptions that affected clinicians into the Workflow Interruption Tool (WIT). Interruption characteristics captured included duration, nature, location, and task priority. Chi-square analysis identified a significant association between interruption type and the interruption priority, p < 0.001. Residents at varying PGY-levels experienced significantly different amounts of interruptions, p=0.013. Observing resident interruptions across the entirety of their shifts identified that as EM residents gain more experience, they are interrupted more often while working in the ED.

Characteristics of team briefings in gynecological surgery

Preoperative briefings have been proven beneficial for improving team performance in the operating room. However, there has been minimal research regarding team briefings in specific surgical domains. As part of a larger project to develop a briefing structure for gynecological surgery, the study aimed to better understand the current state of pre-operative team briefings in one department of an academic hospital. Twenty-four team briefings were observed and video recorded. Communication was analyzed and social network metrics were created based on the team member verbal interactions. Introductions occurred in only 25% of the briefings. Network analysis revealed that average team briefings exhibited a hierarchical structure of communication, with the surgeon speaking the most frequently. The average network for resident-led briefings displayed a non-hierarchical structure with all team members communicating with the resident. Briefings conducted without a standardized protocol can produce variable communication between the role leading and the team members present.

A Preliminary Comparison of Three Tourniquet Instructions for Just-in-Time Guidance of a Simulated Tourniquet Application

The American College of Surgeons (ACS) and the Department of Homeland Security (DHS) encourage the use of tourniquets as part of the “Stop the Bleed” campaign. Both have provided instructions for layperson tourniquet application in order to save the life of a hemorrhaging trauma victim. This study sought to compare the impact of using ACS and DHS instructions with manufacturer-provided instructions for the completion of simulated tourniquet application steps. Thirty surgical trainees completed a simulated tourniquet application with one of the three instruction sets. Their completion time and success for each step were measured. Participants that received ACS instructions failed the fewest number of steps (p < 0.01) and completed the task faster (Mean (SD) = 70 (33) seconds) compared to those with the manufacturer-provided instructions (p < 0.01). Tourniquet instruction sets need to be refined in order to optimize the success rate of just-in-time guidance for tourniquet application.

Improving Instructions to Stop the Bleed

The Stop The Bleed initiative was developed by the Department of Homeland Security to educate lay providers in bleeding reduction strategies. The current study evaluated: (1)three tourniquet instructions using a simulated tourniquet task and (2)participant confidence levels in tourniquet use and lay provider training. Thirty participants with limited clinical experience applied a tourniquet to a simulated limb using one of three instruction sets. Twelve of these participants (40%) participated in a tourniquet training session and focus group to discuss each instruction set. Participants preferred the most simple and pictoral instruction set, and identified opportunities for improvement in each set. Participant confidence in tourniquet use increased significantly following the task and the focus group. After the focus group, participant confidence in instructing lay providers on proper tourniquet use significantly increased. Adding key steps, contextual pictures, and indicators of success to instructions could support lay providers stop the bleed in life-threatening situations.

Do Trauma Activations Affect Interruptions in the Emergency Department

Clinicians have anecdotally indicated that interruptions increase following trauma activations in the emergency department (ED), yet it is unknown whether interruptions change following the end of a trauma case. This study aimed to examine the interruption characteristics of clinicians that participate in trauma activations before and after activations using the SEIPS model. Observers shadowed ED clinicians across entire shifts and logged interruptions that affected clinicians in a tablet PC-based tool. Interruption characteristics captured included duration, nature, location, and task priority. Trauma activations lasting more than five minutes were also recorded. Only interruptions occurring within one-hour of trauma activations were included in the analysis. Chi-square analyses identified significant associations between SEIPS-categorized interruptions and the interruption priority, p < 0.01, and between the SEIPS-categorized interruptions and the interruption location, p = 0.01, pre- and post-trauma activations. Identifying these associations revealed key opportunities to reduce unnecessary interruptions in the ED.