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

https://doi.org/10.1016/j.ijmedinf.2005.03.015Get rights and content

Summary

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Introduction

Data published in the Centers for Disease Control and Prevention's 2004 report National Hospital Ambulatory Medical Care Survey: 2002 Emergency Department Summary indicate that emergency departments (ED) in the U.S. are approaching a boiling point in terms of increasing patient demand and shrinking bed capacity. The report estimates between 1992 and 2002 ED visits increased 15% while the number of EDs decreased 22% [1]. U.S. EDs receive more than 100 million patient visits (80 million adults and 20 million children) per year. ED overcrowding often causes hospital diversion (i.e., ambulances diverted from hospital), increased patient wait times, increased length of stays and decreased patient satisfaction [1], [2], [3], [4], [5]. The crisis is only expected to worsen as increases in non-urgent ED visits drive demand upward and growing financial pressures cause more hospitals to close their EDs. EDs in use today were not designed to handle the volume of patients they are now seeing. For example, the adult ED central to our study, was designed in the 1970's to handle an annual volume of 20,000 patients, but today receives approximately 43,000 patient visits per year.

Just prior to the time that popular media outlets began publishing reports on ED overcrowding in the U.S. (e.g., “ER Conditions Critical”, USA TODAY), the Institute of Medicine (IOM) released its sobering report on medical errors and adverse events in healthcare [6], [7]. In To Err is Human: Building A Safer Health System, the IOM estimated that between 44,000 and 98,000 patients die of iatrogenic injury each year. The emergency department has specifically been identified as a location where adverse events are highly likely to be attributable to error. Studies estimate that the proportion of ED adverse events deemed preventable range from 53 to 82%, compared with overall estimates of 27 to 51% for hospital-based adverse events [8].

Other outcomes, such as patient satisfaction are also suffering in the ED, as demonstrated by recent research findings and increasing rates of patient complaints [9], [10], [11]. Although researchers have reported inconsistent findings concerning which factors lead to patient dissatisfaction in the ED they overwhelmingly agree on two general findings: (1) patients dissatisfaction is on the rise and (2) failures or breakdowns in provider-to-provider and provider-to-patient communications are the primary cause [12]. Communication failures have also been implicated and associated with medical errors and preventable adverse events in the ED [13], [14], [15], [16], [17], [18], [19]. A retrospective review of ED closed claims revealed that teamwork behaviors would have prevented or mitigated the adverse event in 43% of the cases reviewed [20].

In light of the poor outcomes (i.e., safety and satisfaction) associated with acute patient encounters with the ED system, it is evident that there are serious implications for the professionals who work in this environment on a daily basis. In fact, research has shown that emergency physicians and staff experience high rates of stress, depression and career burnout [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32]. Three sets of factors have been shown to contribute to these outcomes in ED personnel: (1) organizational characteristics, (2) patient care and (3) the interpersonal environment.

As the demands on emergency medicine (EM) continue to increase, improvements in the organization of work and the access to timely clinical and system information will be required for providers to manage their workload in a safe and efficient manner. Advances in medical informatics are beginning to facilitate clinical improvements in the ED aimed at addressing these needs. For example, emergency department information systems (EDIS) are being developed that integrate, either in part or in full, the following systems: electronic tracking bed board displays; electronic medical records (EMR); computerized order entry (CPOE) and laboratory and radiology systems. EDIS have great potential to significantly streamline conventional paper-based ED work processes.

The study presented here applied observational methodologies previously employed in the ED and other clinical areas to study and describe provider work and communication processes in an ED equipped with a distributed electronic whiteboard (eWB) [19], [33], [34], [35], [36], [37], [38], [39]. The results of the study are compared and contrasted with results from previously published observational studies performed in EDs unsupported by integrated informatics systems.

Section snippets

Sample population

The study was conducted in the adult emergency department at Vanderbilt University Medical Center (VUMC) in Nashville, Tennessee between September 8, 2003 and May 14, 2004. VUMC is a Level 1 Trauma Center and the adult ED receives over 43,000 patient visits annually. A convenience sample of 10 faculty EM physicians, 5 post-graduate year-three (PGY-3) resident physicians and 5 PGY-2 resident physicians were observed during this period. This sample was selected from the 22 faculty physicians, 8

Work and interruption patterns

In aggregate, 50 h of work activity were observed and recorded for 20 EM physicians working in the VUMC adult emergency department during the study period. Physicians performed 2053 tasks during this time and averaged 103.0 tasks (95% CI, 94.7–111.3) per 180 min observational period. Three-hundred and three interruptions, comprising breaks-in-tasks (N = 93) and temporary interruptions (N = 210), were recorded. On average, PGY-3 residents performed the most tasks (108.0; 95% CI, 99.2–116.8) and

Discussion

This study replicated and expanded the methodology of several previously published observational studies in the ED and other clinical areas to gain some insight on the effects of implementing an integrated electronic whiteboard on physician work, communication and workload in the ED. The results of this study would have been greatly strengthened by using an increased sample size and either a pre–post (i.e., eWB implementation) study design or a randomized clinical trial (RCT). These changes

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