Post on 13-Feb-2016
description
Physician Work, Workload, and Stress in the ED: Implications for Patient SafetyDan France, Ph.D., MPHScott Levin, B.S.23 July 2004
Specific AimsCharacterize ED physician work and communication patterns in the presence of an advanced ED information systemCompare workload and stress in ED attending and resident physiciansExplore methods to quantify effects of system factors on provider and patient outcomes
Emergency Medicine in U.S.How Many ED Visits? 1992-2000Source: National Center for Health Statistics, Source: National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 1992National Hospital Ambulatory Medical Care Survey, 1992--2000200020% increaseNumber of visits Number of visits (in thousands)(in thousands)
Emergency Medicine in U.S.
How Many Hospital Beds? 1992-2000
Source: American Hospital Association, Hospital Statistics
16% decrease
4,547EDs
4,177EDs
8% decrease
Background Emergency MedicineComplex, chaotic, interrupt-driven,Patient Safety: 53% to 82% of ED adverse events (AE) are preventable compared to 27-51% for in-hospital AEs (Fordyce 2003), Risk Management:43% of ED claims due to failures in team communication (Risser 1999)Patient Satisfaction:Ranks high for patient dissatisfaction/complaints (Taylor 2002)
The Burden on PhysiciansResidents experience stress and depression uniformly through training (Whitley 1991)
25-60% of physicians surveyed felt burned out (Doan-Wiggins, Zautcke, etc 1995)
22% of physicians thought they would practice beyond 50 (Losek 1994)
Stress may cause anxiety disorders (Laposa 2003)
Why? Intense clinical workload vs. inefficiencies in workflow, information flow, and communication
Swiss Cheese ModelReason (1990): Human Error
Artichoke ModelBogner (2004): Misadventures in Healthcare
Performance Shaping FactorsIndividual factorsExperience, training, physiological, psychological stateTask-related factorsWorkload, vigilanceEquipment/ToolsHuman-computer/device interactionInterpersonal factorsTeamworkCare environment factorsFacility design/layoutOrganizational/Cultural factors
A Systems Engineering Approach the Inner RingHow do you adequately measure the forces acting on ED physicians from the physicians perspectives?
The Outer Ring ApproachOther hospitals have tried to cope with crowding by expanding the ER, only to find it doesn't solve the problem. Busy Boston Medical Center eases delays by keeping 'customers' moving
emergency room delays are a symptom of poor hospital management
Creating a MethodologyStudy methods from other high risk industries and disciplinesNuclear power, aviation, anesthesiologyHuman factors, psychology, industrial engineerCall your friendsMedicine and Biomedical Eng. Kong Chen, Ph.D.Biomedical informatics Domink Aronsky, M.D., Ph.D,Biostatistics Dan Byrne, M.S., Chang Yu, Ph.D.Emergency Medicine Robin Hemphill, M.D.Dorsey Rickard, Renee Makowski (Med students)Ted Speroff, Ph.D., Bob Dittus, M.D., MPH (Mentors)
Creating a MethodologyCall people you want to be friends with:Bruce Hallbert, M.S. Idaho National Environmental Laboratory (Human Factors expert in Nuclear power)Matt Weinger, M.D. UCSD, anesthesiologist and patient safety expert. Call your friends
Study Design - Conceptual DiagramSubjects:10 Faculty5 PGY-35 PGY-2180-minute observationsAfternoon observations
Primary Task AnalysisPrimary tasks:Answering EMS callsChartingDictatingDirect Patient CareElectronic Whiteboard Interaction (eWB)eWB ViewingExchanging Patient info. Phone calls/PagesVerbal Orders to ProviderTeaching/LearningSupervising
Task Outcomes:End TaskBreak in TaskTemporary interruption
Interruption types:Face-to-Face PhysicianFace-to-face NurseFace-to-face otherPhone call/PageLocating lost chartsEquipment malfunctionOther
Time in Motion Study180 minute observation
Physiological MeasurementsKong Chen, Ph.D.How does physical activity / physiological stress relate mental workload/stress?
Subjective Workload AssessmentNASA Task Load Index (TLX) result of 20 years of research in aviation/space6 Dimensions of NASA-TLXMental demandPhysical demandTemporal demandEffortPerformanceFrustration Level
Electronic WhiteboardED OccupancyDiversion statusPatient wait timesPatient LOSManaging physicianTotal # of ptsMax # of ptsOther system level data
Dominik Aronsky, M.D., Ph.D
Results50 hours of physician work activity observedPhysicians averaged 103 + 19 tasks per observational periodPhysicians walked about 0.8 milesInterruption ratesFaculty: every 9.6 minutesPGY3: every 8.8 minutesPGY2: every 13 minutes
Patient Load by Training Level
pts seen
11.49.8
12.610.8
6.45.6
Total # of patients seen
Max pts seen simulatneously
Sheet1
FacultyPGY-3PGY-2
Total # of patients seen11.412.66.4
Max pts seen simulatneously9.810.85.6
Sheet2
Sheet3
Tasks by Training Level
pts seen
11.49.8
12.610.8
6.45.6
Total # of patients seen
Max pts seen simulatneously
tasks
102.4
108
97.8
Tasks
Sheet1
FacultyPGY-3PGY-2
Total # of patients seen11.412.66.4
Max pts seen simulatneously9.810.85.6
FacultyPGY-3PGY-2
Tasks102.410897.8
Sheet2
Sheet3
Distribution of Tasks
More about TasksFaculty perform 8% more exchanging info, 12% more dictation tasks than residentsResidents perform 10% more charting tasks than facultyResidents performed 59% of all direct patient care tasks
Distribution of Interruptions
More about InterruptionsUninterrupted Task Duration: 0:1:21(hour:minutes:seconds)Interrupted Task Duration:0:2:00 (excluding duration of interruption)Tasks are interrupted about 1 minute after they are startedTemporary interruptions last 33 seconds9% of direct patient care tasks interrupted
What Tasks do Interruptions Interrupt?Face-to-face physicians interruptions:Charting (29%)eWB interaction (22%)Exchanging pt. info (12%)Face-to-face nurse interruptions:Exchanging pt. info (23%)eWB interaction (22%)Charting (16%)Telephone interruptions: Exchanging pt info (22%); direct pt. care (17%), charting(15%)
Task before/After eWB ActivityNote: eWB activity represented nearly 20% of all tasks observed
Subjective Workload by Task
pts seen
11.49.8
12.610.8
6.45.6
Total # of patients seen
Max pts seen simulatneously
tasks
102.4
108
97.8
Tasks
tasks_unint
102.484.7
10883.7
97.888.8
Tasks
% Uninterrupted
unint_tasks
15.3
16.3
11.2
% Tasks interrupted
workloadanddimensions
50.662.845.3
61.987.465.8
6163.561.2
Weighted Workload Scores*
Temporal Demand
Frustration*
wkld_tasks
52.753.754.8
59.871.841.3
67.561.520.5
Charting
Direct Patient Care
Supervising
Sheet1
FacultyPGY-3PGY-2
Total # of patients seen11.412.66.4
Max pts seen simulatneously9.810.85.6
FacultyPGY-3PGY-2
Tasks102.410897.8
% Uninterrupted84.783.788.8
FacultyPGY-3PGY-2
% Tasks interrupted15.316.311.2
FacultyPGY-3PGY-2
Weighted Workload Scores*50.661.961
Temporal Demand62.887.463.5
Frustration*45.365.861.2
Mental demands56.359.944.9
effort50.861.163.8
FacultyPGY-3PGY-2
Charting52.759.867.5
Direct Patient Care53.771.861.5
Supervising54.841.320.5
Sheet1
Weighted Workload Scores*
Temporal Demand
Frustration*
Sheet2
Sheet3
Subjective Workload Dimensions*Statistically significant difference at alpha = 0.05 levelTemporal demandsBiggest driver of workload forall physicians
pts seen
11.49.8
12.610.8
6.45.6
Total # of patients seen
Max pts seen simulatneously
tasks
102.4
108
97.8
Tasks
tasks_unint
102.484.7
10883.7
97.888.8
Tasks
% Uninterrupted
unint_tasks
15.3
16.3
11.2
% Tasks interrupted
workloadanddimensions
50.662.845.3
61.987.465.8
6163.561.2
Weighted Workload Scores*
Temporal Demand
Frustration*
Sheet1
FacultyPGY-3PGY-2
Total # of patients seen11.412.66.4
Max pts seen simulatneously9.810.85.6
FacultyPGY-3PGY-2
Tasks102.410897.8
% Uninterrupted84.783.788.8
FacultyPGY-3PGY-2
% Tasks interrupted15.316.311.2
FacultyPGY-3PGY-2
Weighted Workload Scores*50.661.961
Temporal Demand62.887.463.5
Frustration*45.365.861.2
Sheet1
Weighted Workload Scores*
Temporal Demand
Frustration*
Sheet2
Sheet3
Workload SummaryFaculty supervise; manage information/communication flowPGY-3 residents are the work horses of the EDMost tasks; Most patient care; most interruptionsPGY-2 residents charting;consults; direct patient care
Workload SummaryED physicians attribute mental workload to: Time demands EffortMental demandsResidents have higher workload than facultyResults primarily from frustration; effort
Implications Safety/EfficiencyPhysicians working in ED equipped with IT system (eWB)*Are 34% more efficient (tasks performed)Spend 10% more time on direct patient careExperience 52% less interruptions The eWB appears to help distribute ED workload fairly evenlyThe eWB appears to improve situational awareness Increase in direct patient care after viewing eWB
*Compare to results reported by Chisholm, Coiera, Hollingsworth
Implications Safety/EfficiencyTemporary interruptions occur twice as often as breaks in tasksInterrupted tasks are 33% longer than uninterrupted tasksInterruptions affect provider-provider communication more than provider-patient communicationIT improves information / communication flow but interruptions still prevalentCommand and control center of ED*Compare to results reported by Chisholm, Coiera, Hollingsworth
Next StepsExplore Time-based analysesWorkload densityPhysiological stressLinear mixed effects modelingFramework Assessing Notorious Contributing Influences for Error (FRANCIE)NASA/INEEL tool for aviation safetyModeling human performance and errorInput: Our task analysis data and error taxonomy for EDStudy association between human factors and patient/provider outcomes
Data over time
FRANCIE Core Error and Contributing InfluencesTask or Task Step for AnalysisOmissionCommissionError TypesGeneric ErrorsGeneral Performance shaping factorsIntermediate PSFsSpecific PSFs, PSF characteristics, PSF examples
The FutureDoubling size of Adult EDNew Childrens Hospital EDOther settings OR, Oncology clinics
Questions?
Explain that we used human factors engineering (how do we explain what this is??)Human Factors Engineering is the study of how human behave physically and psychologically in relationship to their environments. It is a diverse field that has roots in psychology, engineering, aviation, computer science, sociology, and anthropology.
Charge nurses:- Important in ED workflow- Meet with Manager of ED nurses, interviewed and followed nurses, and developed a program based off the physician program- BUT multi-task (primary task not clear), short duration tasks- Extensive time to design a new approach to study their role in ED
ED has high burn-out rate likely due to stresses related to multi-tasking, high workload, interruptions, and such varied case presentations
Research shown medical errors and adverse events are more likely to occur in complex and highly dynamic (quick pace, stressed physicians) clinical environments such as the ED
Assuming there are errors and the physicians are well trained, what is the source of the errors?Too much work to do? i.e. patients, acuity, other responsibilities, teachingInefficiencies? i.e. waiting on lab results, waiting for registration, waiting for consults, interruptions, lost charts, ED layoutED has high burn-out rate likely due to stresses related to multi-tasking, high workload, interruptions, and such varied case presentations
Research shown medical errors and adverse events are more likely to occur in complex and highly dynamic (quick pace, stressed physicians) clinical environments such as the ED
Assuming there are errors and the physicians are well trained, what is the source of the errors?Too much work to do? i.e. patients, acuity, other responsibilities, teachingInefficiencies? i.e. waiting on lab results, waiting for registration, waiting for consults, interruptions, lost charts, ED layoutIn addition to collecting information on what providers do, we also collected information on how much time they spend doing it. We also looked at their interaction with technology (whiteboard/computers), patients, and other providers.In addition to collecting information on what providers do, we also collected information on how much time they spend doing it. We also looked at their interaction with technology (whiteboard/computers), patients, and other providers.In addition to collecting information on what providers do, we also collected information on how much time they spend doing it. We also looked at their interaction with technology (whiteboard/computers), patients, and other providers.Expanding:Current: 27 beds, 2 respond rooms, 16,400 sq ftNew: 45 beds, 8 respond rooms in TVC, additional CT, 33,900 sq ft, new layout