Reflective analysis of safety research in the hospital accident & emergency departments
Introduction
The problem of the safety of health care has attracted increasing attention over the past decade. Reports from authoritative bodies (Department of Health, 2000b, Kohn et al., 1999) have been followed by important new initiatives aimed at understanding the ways that failure occurs in health care and, especially at preventing or mitigating those failures. Emergency care has been noted as particularly problematic with respect to safety. Although the proportion of injuries stemming from care in the accident and emergency department (A & E) is not high (compared to the operating theatre, for example), the proportion of injuries believed to be preventable is highest in the A & E (Brennan et al., 1991, Thomas et al., 2000).
However, the problem of improving safety in health care has proven to be a difficult one; a commentary on the 5 years following major increase in research funding for patient safety in the US notes that, although the importance of the issue has become accepted and that attitudes have changed, tangible progress has been slow (Leape and Berwick, 2005). Similarly, efforts to study safety in the A & E have proven more difficult than initially anticipated. In this paper, we explore some of the difficulties that confront human factors professionals who are interested in bringing their special expertise and skills to bear on the problems of safety in health care in general and the A & E in particular based on our experience in the US and the UK. The final section of the paper suggests some possible ways forward.
The emergency department is a complex and difficult environment in which to provide medical care and differs substantially from more traditional settings in health care organizations (Heartfield, 2000). This makes it more vulnerable to incidents and adverse events. It also makes it potentially more interesting to human factors professionals, as it affords opportunities for learning about human performance as individuals, groups, and teams, in a complex, uncertain and unforgiving environment. Wears et al. (2003c) have identified six factors that characterize the emergency environment:
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Care is ‘unbounded’ in the sense that the A & E is the only part of the hospital where any number of patients can be admitted and held. It is the only ‘infinitely expansible’ part of the hospital.
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Emergency caregivers typically treat many patients simultaneously and in a much greater variety than do caregivers in other settings; for example, typically they must simultaneously manage children and adults, surgical and medical complaints, life-threatening and trivial conditions. This requires frequent suspension and switching of context.
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The level of uncertainty is much greater than in other areas, for two reasons. First, the presenting complaints are almost entirely undifferentiated, as there is no limit to the range of problems that may be encountered; and second, important data are often missing or practically unavailable during emergency care (Stiell et al., 2003).
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The time constraints of A & E care are severe, for 2 reasons. First, for some emergent conditions, the window of opportunity in which action can be effective is short, so clinicians must rapidly commit to a course of action without waiting for greater certainty if they are to have any chance at success. Second, the physician–patient encounter is typically brief. In the US, experienced physicians must average between 4 to 6 patient encounters per hour during peak times. The rate is much lower in the UK (around 1 per hour), but roughly 70% of patients there are seen by junior physicians in training, who may be only 12 months since qualifying from medical school. Since the rate of patient arrivals at peak hours is typically considerably higher than the staffs' ability to keep pace, providers are usually working against a backlog of cases. In the UK, this pressure has been increased by the introduction of standards requiring that 100% of patients be either admitted or discharged within 4 hours of checking in to the A & E (Department of Health, 2000a), with only a 2% allowance for breaching this target in special circumstances.
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Emergency caregivers receive little or no feedback on the results of their care, making it almost impossible to learn from experience. Systems for routinely returning outcome information (such as discharge data, diagnostic data and clinical outcomes) to emergency practitioners are uncommon or nonexistent, and well-integrated patient record systems across all settings of care are uncommon at this time.
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Finally, emergency clinicians have little opportunity for safe repetition of the riskiest procedures under non critical conditions. For example, the most dangerous parts of anesthesia are induction and recovery, but anaesthetists routinely carry out these procedures several times daily, whereas in the A & E, the riskiest procedures (eg, emergency intubation, thrombolysis) are among the least commonly performed; sometimes in the order of monthly, yearly or even less frequently for an individual practitioner.
These six factors are not the only ones that affect performance in A & E; for example, shift work, sleep loss, and heavy dependence on services outside the A & E's control (laboratory, radiology, consulting services, etc) also play a role.
Another important crucial factor in the British context is the relatively junior level of the majority of staff in the A & E and the sometimes inadequate level of training and skills brought to major emergencies. In addition, the use of other independent practitioners in A&E is increasing. Emergency Nurse Practitioners can function autonomously after a short training period (6 weeks); these and other physician extenders (eg, paramedics) can discharge “minors” cases without review by senior colleagues. This is compounded by a rapid turnover among nurses, particularly in some busy inner city hospitals. Furthermore, in countries such as the UK where emergency medicine is a relatively new specialty, only about 30% of patients are reviewed by a physician with more than 18–24 months experience, and that review is initiated by the junior physician, rather than being performed systematically. The recent introduction of European Union directives limiting doctors' working hours to a maximum of 48 per week may have reduced the effect of fatigue on performance but there are concerns about their effect on experiential learning. Overall patient contact hours have been reduced by 14%, in addition to a reduction in the total length of training in the UK. These training changes are relatively recent (2006) and will not reach take full effect until 2009, so their effects have not been completely assessed.
There have been few focused investigations of errors, incidents and adverse events in the A & E, and even fewer into their nature and contributory factors. What is available in the literature offers glimpses of the problem but does not provide a great deal of understanding into the origin, nature, causes or prevention of errors and incidents.
Major epidemiological investigations have consistently identified significant rates of preventable error occurring in emergency departments (Brennan et al., 1991, Thomas et al., 2000, Wilson et al., 1995, Wilson et al., 1999). These studies all suggest that while emergency care accounts for only a few percent of the total adverse events in hospitalized patients, roughly ¾ of them were judged highly preventable, a proportion much higher than any other area of care. Because these studies were based on record reviews, and only included inpatients (while roughly 80% of A & E patients are not admitted to inpatient units), it is likely that the burden on preventable injury is even higher.
More direct studies of emergency care have borne out these results, both globally (Boreham et al., 2000, Fordyce et al., 2003) and in specific problem areas such as chest pain and cardiac disease (Lee et al., 1987), patient complaints and negligence cases (Kadzombe and Coals, 1992, Karcz et al., 1990, Karcz et al., 1993, Karcz et al., 1996).
A variety of studies have identified specific human factors and ergonomics issues important to safety in the A & E. The workplace of the A & E often has notable design issues from an ergonomics perspective that have only recently begun to come to the surface (Wears and Perry, 2002).
In addition, interruptions in the A & E are frequent (Chisholm et al., 2000, Chisholm et al., 2001, Chisholm et al., 1998), averaging roughly once every 6 min, and that most interruptions led to a change in task. Similarly, observational studies have shown that direct communication among caregivers is particularly important (Fairbanks et al., 2007, Woloshynowych et al., 2007), although almost 1/3 of the communications were interruptions (Coiera et al., 2002, Matthews et al., 2002, Vincent and Wears, 2002), suggesting that the combination of interruptions and multiple concurrent tasks may contribute to failures.
A & E care is accomplished by a complex, joint cognitive system consisting of people, artefacts, and procedures. Building and maintaining coordination in this system is not an easy task, and the high levels of communication activity, and even to some extent the interruptions, are essential in maintaining this coordination. Studies on team behaviour in the A & E have suggested that teamwork failures are frequently found in relation to adverse events (Risser et al., 1999), and further that structured teamwork training can improve team behaviours and reduce observed errors (Morey et al., 2002).
In addition to teamwork, clinicians in the A & E use a variety of cognitive artefacts to support their individual and collective work. Shared status boards, whether manual “white-boards” or computerized information systems, are ubiquitous in all but the smallest settings. They have been identified as essential coordinative devices (Wears and Perry, 2007, Wears et al., 2007b), and studies of changes to the status board have shown unanticipated consequences for safe practice (Pennathur et al., 2007, Pennathur et al., 2008, Wears et al., 2003a).
Because emergency care is provided on a 24 × 7 basis, care providers necessarily work in shifts. This requires “hand-overs” of patients from one provider to another at shift changes. Such transitions in care have long been thought to be relatively dangerous times (Delays in Treatment, 2002), but have been little studied (Wears et al., 2003b).
Section snippets
What makes studying clinical work difficult?
A field of practice where vulnerabilities abound, risk is high, and failure a constant threat would seem a natural laboratory for human factors professionals interested in understanding and improving human performance under demanding conditions. But, our experience in both the US and the UK has demonstrated multiple barriers to effective research efforts.
Discussion
In this section we propose some strategies that might be used to manage some of the issues and difficulties outlined previously. We will not dwell on problems which human factors professionals are likely to have had experience with in other fields (such as gaining the trust of the subjects, or learning how to “see” the difficulties and adaptations in complex work that skilled practitioners make seem easy).
The issue of developing sustained collaborations resides at a higher level than the
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