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