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Research shows that emergency physicians may be interrupted 10-15 times per hour, leading to the potential for errors and patient harm. However, experts note that an array of relatively simple strategies can help clinicians better manage these interruptions to both minimize related mistakes and potentially ease the frustration that results from continuous interruptions.
It’s no secret that EDs are busy, fast-paced environments. Clinicians going into this field recognize that pressure and stress are part of the package. However, how they handle this stress, particularly how they manage the frequent disruptions that go along with repeated interruptions, can make a difference in terms of patient safety as well as a clinician’s own well-being.
New research suggests there is ample room for improvement in this area. Through the use of relatively simple strategies, providers could act more proactively to mitigate the potentially harmful effects that go along with repeated interruptions while preforming important healthcare tasks over the course of a shift in the ED.1
“What we know about task disruptions is that they are highly, highly disruptive, and what we also know about the ED is that task interruptions are very frequent,” explains Raj Ratwani, PhD, the scientific director and senior research scientist at the National Center for Human Factors in Healthcare at the MedStar Institute for Innovation in Washington, DC.
To quantify the problem, Ratwani notes studies have shown that an emergency physician might be interrupted anywhere between 10 and 15 times per hour. Those interruptions result in errors that can cause patient harm and the potential for patient harm.
“[The interruptions] also are very disruptive to the cognitive processes of the emergency physician, meaning that they disrupt the way the physician is thinking, working, and reasoning with information,” he explains. In addition to causing errors and disrupting thought processes, disruptions are very frustrating to physicians, Ratwani notes.
“They contribute to the problems around physician burnout and physician stress,” he adds.
To paint a picture of how these disruptions commonly lead to errors, Ratwani offers the example of a physician who is standing at a workstation and placing a medication order for a patient.
“The physician might get interrupted by a nurse asking whether a patient in a particular room is allowed to eat,” he says. “The physician may direct his or her attention to that nurse to answer the question and then come back to the screen and input incorrect information or skip a step when entering important information on the medication order.”
Alternatively, when a physician is placing a medication order for patient A, a nurse might come by and say that patient B needs a medication order right away. In this instance, the physician may go to place the medication order for patient B without changing the screen, inadvertently ordering a medication for the wrong patient.
“That is a mix-up that occurs using the health information technology [IT] system when physicians get interrupted and their thought processes get disrupted,” Ratwani observes.
Although interruptions related to computer use are the most prevalent, they can occur under many other circumstances as well, such as while a physician is reviewing paperwork or even while he or she is walking to see a patient in a room, Ratwani explains. The physician may be anticipating what questions to ask that patient or formulating a possible diagnosis in advance of an encounter, he says. However, this thought process can be disrupted by a nurse or a tech who stops the physician to ask about a different patient.
“Where we see fewer interruptions is actually in the patient room itself, so people generally recognize that is protected time between the physician and the patient,” Ratwani adds.
Of course, many interruptions are indeed necessary and important. However, there are strategies clinicians can use to better manage them so that interruptions are less likely to lead to errors. For example, if clinicians recognize they are performing a high-risk task and someone begins to interrupt them, clinicians can move to delay or defer the interruption.
“You can ask the [interrupting person] to wait a minute and then complete your task, or you can ask them to come back at another time,” Ratwani suggests. “At a very base level, that is the first thing that clinicians can do, and they should feel empowered to do that when they recognize that they are doing something that should not be interrupted.”
Further, Ratwani points to three primary strategies available for cases in which clinicians decide that they need to accept and engage in the interruption. In these instances, the goal is to reduce the disruptiveness of the interruption, he observes. Ratwani notes that one way to do this is to set up environmental cues or what is essentially a reminder system so that clinicians can easily go back to the task they were performing once they have handled the interruption.
For example, say a clinician is in the process of placing a medication order, Ratwani offers. “If you are working on the computer and you leave your mouse right where you were last working — the field where you were just about to put information in, and you then turn to the interrupter and deal with the interruption, when you come back you will then know where you were in the ordering process,” he says. “If you deliberately set that up, it helps you to remember to go back to that position.”
An alternative to using mouse placement as an environmental cue involves placing a sticky note right where one left off in the ordering process when the interruption occurred. For instance, this could be right at the point of entering the dose information for a particular patient.
“That gives you that extra little reminder that this is what you were last doing,” Ratwani notes.
A second strategy that can be helpful in minimizing missteps due to interruptions is what Ratwani calls memory rehearsal. “The basic idea is when you are first getting interrupted, if you repeat to yourself the goal or the task that you are working on, it helps you to recall that memory once the interruption is over,” he explains.
The way this would work is if a clinician is placing a medication order and is interrupted, before moving on to engage in the interruption the clinician would take a moment to repeat what he or she is doing.
“That helps the memory element in your head stay highly activated so that the minute you come back to the task [after dealing with the interruption], it is easier for you to recall what you were doing,” Ratwani explains.
Finally, a third strategy that can help clinicians better manage interruptions involves continuing to work at the original task until they get to what Ratwani refers to as a break point, a place in the task from which it will be easier to resume the activity after the interruption has been addressed.
“If you are reading a paragraph of text, and you get interrupted and stop reading mid-sentence, that is a difficult place to come back to because you haven’t formalized and finished that complete sentence or that complete task; whereas if you break at the end of the sentence or you break at the end of the paragraph, it is easier for you to come back,” Ratwani observes. “Similarly, if you are working on a task of placing a medication order, instead of stopping while you are typing in the dosage information, if you just give it 10 more seconds and complete that dosage information — or even get to a strong stopping point in the medication task itself — it becomes easier to resume. Actually recognizing where you are stopping your work and being deliberate about where you stop your work is another great strategy.”
Unfortunately, while such strategies are relatively simple and straightforward, research completed by Ratwani and colleagues suggests that emergency providers are not using the tactics in significant numbers. This, despite the fact that emergency physicians often are exasperated by constant interruptions.
“What we are finding is that there is actually a pretty big appetite [for new solutions] because physicians are getting so frustrated with the number of times they are getting interrupted,” Ratwani notes. “Number one, they recognize themselves that [interruptions] can be unsafe, and number two, they are really stressful.”
In fact, Ratwani says that several physicians have contacted his group at the Institute for Innovation to ask for pointers on how to better manage interruptions.
“We can do this very quickly. It doesn’t have to involve expensive training, and then it involves the physician putting the strategies into practice,” he offers. “They have to really think about the way they do their work and the way they handle interruptions, and then practice using these strategies.”
Most physicians can acquire and adapt the practices to their own work environments quite readily, Ratwani observes.
“Physicians are incredibly bright, and many of them already have some of their own strategies in place, so when you get them into the meta-cognitive process of thinking about how they think and how they do their work, they are quite good at formulating strategies,” he says. “Everyone has their own way of ... tracking which patients they have seen and tracking which patients need further attention, so they can quickly adopt these practices and bring them into their own workflow and their own work process.”
While medical personnel always seem open to considering new approaches when an error has occurred, Ratwani notes that he has found physicians most receptive to new solutions in this area when they see how much the interruptions are affecting their work. “It is when they’ve just recognized that they are leaving work so frustrated and stressed, and they can see that they can’t get anything done effectively because of all the interruptions in their environment,” he explains.
Certainly, IT prompts could help EDs implement some of the strategies that Ratwani recommends. For example, given that computer systems can detect when there is a period of no activity, they could then be programmed to highlight a field where the user was engaged last or construct arrows showing the last three steps the user completed before leaving the computer to handle an interruption.
“There are many cues that could be introduced computationally that would alleviate the memory burden on the physician,” Ratwani explains.
Other high-risk industries such as defense and aviation have recognized the problems associated with interruptions and have devised ways to minimize them, Ratwani notes. For example, he says sterile cockpits are mandated during takeoffs and landings, eliminating the possibility of any interruptions during these critical periods. However, healthcare is unique in some ways.
“The challenge in emergency medicine is that oftentimes the interruptions are a necessary part of delivering care,” Ratwani laments. “Not all interruptions are bad. Sometimes you need to be interrupted. If you have a patient who is coding or a high-severity patient who has just come in, the physician wants to know and needs to know.”
This is why strategies to manage these interruptions are important, Ratwani observes. “You can’t just shut down the interruptions and make [the ED] a completely sterile environment. That won’t work,” he adds.
Further, while Ratwani’s current research focuses on physicians, he stresses that interruptions affect other types of healthcare personnel as well.
“Other researchers have looked at how often nurses get interrupted and how often other types of clinicians in emergency medicine get interrupted, and interruptions happen across the board,” he says. “Now, it is at varying levels of frequency, of course, and probably at varying levels of severity, depending on the tasks [the clinicians] are taking on.”
For instance, Ratwani notes that his group found that radiologists get interrupted between nine and 10 times per hour, enough to be highly disruptive to their work. “The problem is pervasive across healthcare, [although] emergency medicine certainly seems to be where there are far more frequent disruptions compared to other clinical environments,” he adds.
Knowing that interruptions are highly stressful, investigators are evaluating the physiological response of emergency physicians to their work environment.
“We are looking at their heart rate, heart rate variability, and respiratory rate so that we can try to reduce the level of stress in our physicians,” Ratwani explains.
Further, now that it is clear emergency physicians are not employing the kinds of strategies that could help them manage interruptions as readily as they could, researchers are trying to find ways to instill these strategies into their practice without placing added burdens on physicians or the ED.
“Physicians have enough training they have to go through, so we really don’t want to add another training around interruptions,” Ratwani notes. “If we can take [this information] and layer it into trainings or simulations that physicians are already doing, I think that would be the best approach.”
A third investigative project is focused on finding ways to minimize the need for interruptions in the first place. Ratwani says that it is a matter of looking at the interruptions problem in a more holistic way to root out inherent shortcomings with the health IT system, processes, or workflows that may be driving the need for interruptions.
Financial Disclosure: Physician Editor Robert Bitterman, Author Dorothy Brooks, Editor Jonathan Springston, Executive Editor Shelly Morrow Mark, and Editorial Group Manager Terrey L. Hatcher report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.