Patient safety at emergency departments : challenges with crowding, multitasking and interruptions

Sammanfattning: Several challenges with patient safety in the emergency department (ED) context have been previously identified, and some commonly mentioned are crowding, multitasking, and interruptions. The ED is a complex, high-risk work environment where multiple clinicians (physicians, registered nurses [RNs], and licensed practical nurses [LPNs]) are constantly working in parallel work processes, in an often crowded ED, while conducting tasks involving cognitively demanding decision-making processes. ED crowding has for the past 20 years been identified as a problem internationally, resulting in extended ED length of stay (LOS) and increased morbidity and mortality for patients. ED crowding is also considered to have negative effects on the clinicians’ workload and work satisfaction. Both multitasking and interruptions have been identified as risk factors for patient safety by having negative effects on a clinician’s decision-making processes and thus increasing the risk of forgetting important details and events because of memory overload. However, information has been lacking about what specific work assignments ED clinicians conduct, and thus there is little information about the types of assignments they perform while multitasking and being exposed to interruptions. Further, because not all interruptions lead to errors and because they are not all preventable, a more refined account of interruptions is called for. Moreover, it seems that previous studies have not identified which specific factors influence the ED clinicians’ perceptions of interruptions. The work environment has been referred to as a possible influencing factor, but specific details on the relationship between the work environment and negative effects from interruptions are pending. The overall aim of the thesis was to describe ED crowding, and its influence on ED clinicians’ work processes (activities, multitasking, and interruptions) and patient outcomes, from a patient safety perspective. The thesis addressed six research questions: 1) How has ED characteristics, patient case mix and occurrence of ED crowding changed over time? 2) What work activities are performed by ED clinicians? 3) What kind of multitasking situations are clinicians exposed to during ED work? 4) What kind of interruptions are clinicians exposed to during ED work? 5) How do ED clinicians perceive interruptions? 6) Is there an association between ED crowding and mortality for stable patients without the need for acute hospital care upon departure from the ED? The data in the thesis were generated from two data collections: 1) registry data containing patient characteristics and measures of ED crowding (ED occupancy ratio [EDOR], ED LOS, and patient/clinician ratios) extracted from the patients’ electronic health records (paper I and IV) and 2) observations and interviews with ED clinicians (physicians, RNs, and LPNs) (paper II and III). Nonparametric statistics were used in paper I and III, quantitative and qualitative content analysis were used in paper II and III, and multivariate logistic regression analysis was used in paper IV. The main results in the thesis are presented based on Asplin’s conceptual model of ED crowding, from the aspect of input-throughput-output, and how parts of a sub-optimal throughput influence patient safety through ED clinicians’ work processes and patient outcomes. During 2009 – 2016 there has been a change in patient case mix at the EDs at the study hospital, primarily with an increase in unstable patients (input) and a decrease in the number of patients admitted to in-hospital care (output). The median for ED LOS over the study period increased, and the largest increases occurred among the subgroups of unstable patients, patients ≥80 years of age, and those admitted to in-hospital care (throughput). Further, an increase in crowding, in terms of median EDOR and median patients per RN ratios, was identified, with an increase in EDOR from 0.8 in 2009 to 1.1 in 2016 and an average increase of 0.164 patients/RN/year (throughput). The ED clinicians’ work assignments consisted of 15 categories of activities, and information exchange was found to be the most common activity (42.1%). In contrast, the clinicians only spent 9.4% of their activities on direct interaction with patients and their families (ED clinicians’ work processes). The clinicians multitasked during 23% of their total number of performed activities, and there was an overall interruption rate of 5.1 interruptions per hour. The majority of the observed multitasking situations and interruptions in the ED clinicians’ work occurred during demanding activities that required focus or concentration (ED clinicians’ work processes). Finally, an association was identified between an increase in ED LOS and EDOR and 10-day mortality for stable patients without the need for acute hospital care upon departure from the ED (patient outcomes). This thesis illustrates how a sub-optimal throughput, affected by conditions in both the input and output components, negatively influence the ED clinicians’ work processes as well as patient outcomes.