Original Contributions
Work interrupted: A comparison of workplace interruptions in emergency departments and primary care offices*,**,*,**

https://doi.org/10.1067/mem.2001.115440Get rights and content

Abstract

Study Objective: We sought to determine the number of interruptions and to characterize tasks performed in emergency departments compared with those performed in primary care offices. Methods: We conducted an observational time-motion, task-analysis study in 5 nonteaching community hospitals and 22 primary care offices in 5 central Indiana cities. Twenty-two emergency physicians and 22 office-based primary care physicians (PCPs) were observed at work. The number of interruptions, tasks, simultaneous tasks, and patients concurrently managed were recorded in 1-minute increments during 150- to 210-minute observation periods. Results: Emergency physicians were interrupted an average of 9.7 times per hour compared with 3.9 times per hour for PCPs, for an average difference of 5.8 times per hour (95% confidence interval [CI] 4.2 to 7.4). PCPs spent an average of 11.4 minutes per hour performing simultaneous tasks compared with 6.4 minutes per hour for emergency physicians (average difference, 5.0 minutes; 95% CI 1.2 to 8.8). Emergency physicians spent an average of 37.5 minutes per hour managing 3 or more patients concurrently compared with 0.9 minutes per hour for PCPs. PCPs spent significantly more time performing direct patient care, and emergency physicians spent significantly more time in analyzing data, charting, and taking reports on patients. Conclusion: Emergency physicians experienced more interruptions and managed more patients concurrently than PCPs. PCPs spent more time performing simultaneous tasks than emergency physicians. Our study suggests there are important ergonomic differences between emergency medicine and office-based primary care work environments that may require different training approaches, design considerations, and coping strategies. [Chisholm CD, Dornfeld AM, Nelson DR, Cordell WH. Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med. August 2001;38:146-151.]

Introduction

Sociologist Lewis Mumford lamented, “Today, the degradation of the inner life is symbolized by the fact that the only place sacred from interruption is the private toilet.”1 And this was written in 1938, before the advent of beepers and cellular telephones. Attentional dynamics, those factors that govern the control of attention and the management of mental workload, are some of the important cognitive factors that affect the performance of practitioners in a complex setting, such as medicine.2 Such factors are critical in reducing error in health care because the practitioner whose attention is constantly shifting from one item to another may not be able to formulate a complete and coherent picture of the state of the system.2

We previously studied how emergency physicians and emergency nurses spend their time in emergency departments, finding that almost half their time was spent on indirect patient care activities.3 We then conducted an observational study in the same EDs, as well as in a community and rural hospital ED, that examined the same number and types of interruptions encountered, as well as the number of patients concurrently under the care of emergency physicians and the number of tasks they performed.4 Because the emergency physicians were interrupted an average of 10.3 times per hour, we concluded that emergency physicians were both “interrupt driven” and “multitasking,” terms borrowed from the computer sciences lexicon.

Interrupt-driven computer programs receive interrupt signals that cause them to temporarily suspend their current activity. Unlike computers that mindlessly pick up where they left off, human beings often find themselves distracted and unable to concentrate when they return to tasks after interruptions.5 Ozawa noted, “Critical thinking and analysis get lost in an interrupt-driven workplace.”5 The term multitasking refers to managing multiple tasks simultaneously.

The number of workplace interruptions may be an important ergonomic factor contributing to inefficiency, increased error, stress, and job dissatisfaction in both health care and non–health care workplaces. Little research, however, has been conducted to compare interruption rates among different medical practices where workloads and other ergonomic and practice characteristics may differ. For example, because patient visits to the ED are unscheduled, there are irregular peaks and troughs in the number of patients and severity levels of illness and injury. Emergency physicians must often shift their attention to prioritize the unannounced arrival of critically ill or injured patients. Because we are unaware of any study that has compared the ED work environment with the primary care work environment, we conducted an observational study to determine the number of interruptions and simultaneous tasks in both workplaces. Our null hypothesis stated that there are no differences in the number of interruptions and simultaneous tasks between emergency physicians and primary care physicians (PCPs).

Section snippets

Materials and methods

Twenty-two emergency physicians in 5 nonteaching community hospitals and 22 PCPs (6 pediatric, 6 internal medicine, 6 family medicine, and 4 internal medicine-pediatric physicians) were observed in their work environments from June 12 through August 1, 1998. None of the study sites were postgraduate medical training facilities. The primary care study sites were located in the Indianapolis metropolitan area and included both private and managed care practices. The EDs were located in 5 smaller

Results

Demographic data and main results are reported in Table 3.There were more women in the PCP group (40.9%) compared with the emergency physician group (14.3%), which approached statistical significance (P =.052, χ2 test). Other demographic variables did not approach statistical significance between the 2 groups, indicating that they were generally comparable.

Emergency physicians were interrupted nearly 3 times more than their primary care counterparts. Emergency physicians experienced

Discussion

In this observational study, both PCPs and emergency physicians were frequently interrupted. The higher number of interruptions for the emergency physician likely reflects the differences in the work environments, as well as the limits of the study design. Emergency physicians are hospital-based shift workers caring for unscheduled patients in a work environment typified by peaks and troughs of patient influx. Their work shifts (typically 8-12 hours in length) provide coverage 24 hours a day, 7

Acknowledgements

Author contributions: CDC and WHC conceived the study. CDC, AMD, DRN, and WHC designed the study, analyzed and interpreted the data, drafted the manuscript, and contributed substantially to its revision. DRN served as the project statistician. As described in greater detail in the Methods section, AMD collected the study data. CDC takes responsibility for the paper as a whole.

We thank the 44 physicians who graciously allowed us to evaluate their practice environments.

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Ms. Dornfeld is currently a medical student at Stritch School of Medicine of Loyola University, Chicago, IL, and Mr. Nelson is currently with the Department of Biostatistics, Cleveland Clinic, Cleveland, OH.

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Author contributions are provided at the end of this article.

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Supported by a Methodist Hospital Student Summer Research Program grant (Ms. Dornfeld).

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Reprints not available from the authors.

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