The multitasking clinician: Decision-making and cognitive demand during and after team handoffs in emergency care

Abstract

Several studies have shown that there is information loss during interruptions, and that multitasking creates higher memory load, both of which contribute to medical error. Nowhere is this more critical than in the emergency department (ED), where the emphasis of clinical decision is on the timely evaluation and stabilization of patients. This paper reports on the nature of multitasking and shift change and its implications for patient safety in an adult ED, using the methods of ethnographic observation and interviews. Data were analyzed using grounded theory to study cognition in the context of the work environment. Analysis revealed that interruptions within the ED were prevalent and diverse in nature. On average, there was an interruption every 9 and 14 min for the attending physicians and the residents, respectively. In addition, the workflow analysis showed gaps in information flow due to multitasking and shift changes. Transfer of information began at the point of hand-offs/shift changes and continued through various other activities, such as documentation, consultation, teaching activities and utilization of computer resources. The results show that the nature of the communication process in the ED is complex and cognitively taxing for the clinicians, which can compromise patient safety. The need to tailor existing generic electronic tools to support adaptive processes like multitasking and handoffs in a time-constrained environment is discussed.

Introduction

The working environment of an emergency department (ED) is a unique, complex and dynamic environment. This is reflected in the varying, often overwhelming volume of patients seen in busy emergency departments as well as the range of acuity of clinical encounters [1]. In addition, an ED is an example of a multifaceted organization composed of complex social environments, where interruptions are frequent and disruptive [2], [3], [4]. Such environments, where decisions are made under time pressure and with incomplete information, have been considered conducive to error [5]. Studies such as the Harvard Medical Practice Study reported that approximately 1.5–3% of observed adverse events occurred in emergency departments [6]. Most importantly, these studies found that emergency departments had the highest proportion of preventable errors, which were most commonly diagnostic errors. This data suggests that cognitive errors associated with clinical decision-making are critically important to the ED [7]. Some researchers have suggested that the nature of decision-making should not be studied in isolation from other processes such as situation awareness, problem solving, uncertainty management and the development of expertise [8]. In parallel, the patient safety movement has evolved from a “phenotypic” study of the surface descriptors of medical error (the who, what, where and when of adverse events) to a “genotypic” approach that seeks to identify how people, teams, and organizations coordinate activities, information, and problem solving in order to cope with the complexities of situations that can arise in daily life [9]. The link between cognitive error and decision-making, and the importance of characterizing the context in which they are interconnected, necessitates the naturalistic study of error in emergency departments [10].

Our study was conducted in the naturalistic environment of the emergency department in order to characterize the factors that constrain safe decisions in patient care. In this paper, we focus on the nature of interruptions, multitasking and shift change that have been recognized as important patient safety issues in dynamic clinical environments [2], [11], [12].