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Patient safety at emergency departments: challenges with crowding, multitasking and interruptions
Department of Medicine, Solna, Karolinska Institutet.ORCID iD: 0000-0003-1815-799x
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Several challenges with patient safety in the emergency department (ED) context have beenpreviously identified, and some commonly mentioned are crowding, multitasking, andinterruptions. The ED is a complex, high-risk work environment where multiple clinicians(physicians, registered nurses [RNs], and licensed practical nurses [LPNs]) are constantlyworking in parallel work processes, in an often crowded ED, while conducting tasksinvolving cognitively demanding decision-making processes. ED crowding has for the past20 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 tohave negative effects on the clinicians' workload and work satisfaction.

Both multitasking and interruptions have been identified as risk factors for patient safety byhaving negative effects on a clinician's decision-making processes and thus increasing therisk 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 whilemultitasking and being exposed to interruptions. Further, because not all interruptions lead toerrors and because they are not all preventable, a more refined account of interruptions iscalled for. Moreover, it seems that previous studies have not identified which specific factorsinfluence the ED clinicians' perceptions of interruptions. The work environment has beenreferred to as a possible influencing factor, but specific details on the relationship between thework environment and negative effects from interruptions are pending.

The overall aim of the thesis was to describe ED crowding, and its influence on EDclinicians' work processes (activities, multitasking, and interruptions) and patient outcomes,from a patient safety perspective. The thesis addressed six research questions: 1) How has EDcharacteristics, patient case mix and occurrence of ED crowding changed over time? 2) Whatwork activities are performed by ED clinicians? 3) What kind of multitasking situations areclinicians exposed to during ED work? 4) What kind of interruptions are clinicians exposedto during ED work? 5) How do ED clinicians perceive interruptions? 6) Is there anassociation between ED crowding and mortality for stable patients without the need for acutehospital care upon departure from the ED?

The data in the thesis were generated from two data collections: 1) registry data containingpatient 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 andIV) 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 regressionanalysis was used in paper IV.

The main results in the thesis are presented based on Asplin's conceptual model of EDcrowding, from the aspect of input-throughput-output, and how parts of a sub-optimalthroughput influence patient safety through ED clinicians' work processes and patientoutcomes. During 2009 – 2016 there has been a change in patient case mix at the EDs at thestudy hospital, primarily with an increase in unstable patients (input) and a decrease in thenumber of patients admitted to in-hospital care (output). The median for ED LOS over thestudy period increased, and the largest increases occurred among the subgroups of unstablepatients, 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 RNratios, was identified, with an increase in EDOR from 0.8 in 2009 to 1.1 in 2016 and anaverage increase of 0.164 patients/RN/year (throughput). The ED clinicians' workassignments consisted of 15 categories of activities, and information exchange was found tobe the most common activity (42.1%). In contrast, the clinicians only spent 9.4% of theiractivities on direct interaction with patients and their families (ED clinicians' workprocesses). The clinicians multitasked during 23% of their total number of performedactivities, and there was an overall interruption rate of 5.1 interruptions per hour. Themajority of the observed multitasking situations and interruptions in the ED clinicians' workoccurred during demanding activities that required focus or concentration (ED clinicians'work processes). Finally, an association was identified between an increase in ED LOS andEDOR and 10-day mortality for stable patients without the need for acute hospital care upondeparture from the ED (patient outcomes).

This thesis illustrates how a sub-optimal throughput, affected by conditions in both the inputand output components, negatively influence the ED clinicians' work processes as well aspatient outcomes.

Place, publisher, year, edition, pages
Stockholm: Karolinska Institutet, Dept of Medicine, Solna , 2018.
National Category
Health Sciences
Identifiers
URN: urn:nbn:se:du-35003ISBN: 978-91-7549-892-8 (print)OAI: oai:DiVA.org:du-35003DiVA, id: diva2:1468455
Public defence
2018-12-14, Rolf Luft, L1:00, Anna Steckséns gata 53, Karolinska University Hospital, Solna, 09:00 (English)
Opponent
Supervisors
Available from: 2020-09-18 Created: 2020-09-18 Last updated: 2020-09-18Bibliographically approved
List of papers
1. Significant changes in emergency department length of stay and case mix over eight years at a large Swedish University Hospital
Open this publication in new window or tab >>Significant changes in emergency department length of stay and case mix over eight years at a large Swedish University Hospital
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2019 (English)In: International Emergency Nursing, ISSN 1755-599X, E-ISSN 1878-013X, Vol. 43, p. 50-55Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Describe the longitudinal development of crowding and patient/emergency department (ED) characteristics at a Swedish University Hospital.

METHODS: A retrospective longitudinal registry study based on all ED visits with adult patients during 2009-2016 (N = 1,063,806). Patient characteristics and measures of ED crowding (ED occupancy ratio, length-of-stay [LOS], patients/clinician's ratios) were extracted from the hospital's electronic health record. Non-parametric analyses were conducted.

RESULTS: The proportion of unstable patients (triage level 1-2) increased while the proportion of admitted patients decreased. All crowding variables were stable, except for LOS, which increased by 9 min/visit/year (95% CI: 8.8-9.1). LOS for visits by patients ≥ 80 years increased more compared to those 18-79 (248 min vs. 190 min, p < 0.001). Unstable patients increased their median LOS compared to stable patients (triage level 3-5). LOS for discharged patients increased with an average of 7.7 min/year (95% CI: 7.5-7.9) compared to 15.5 min/year (95% CI: 15.2-15.8) for those being admitted.

CONCLUSION: Fewer admissions, despite an increase of unstable patients, is likely related to lack of in-hospital beds and contributes to ED crowding. The increase in median ED LOS, especially for patients in the subgroups unstable, ≥80 years and admitted to in-hospital care reflects this problem.

Keywords
Clinicians, Crowding, Emergency department, Health policy, Patient safety, Physician, Quantitative, Registered nurse, Work environment
National Category
Health Sciences
Research subject
Research Profiles 2009-2020, Health and Welfare
Identifiers
urn:nbn:se:du-28476 (URN)10.1016/j.ienj.2018.08.001 (DOI)000460680600009 ()30190224 (PubMedID)2-s2.0-85052831113 (Scopus ID)
Available from: 2018-09-11 Created: 2018-09-11 Last updated: 2021-11-12Bibliographically approved
2. An observational study of activities and multitasking performed by clinicians in two Swedish emergency departments
Open this publication in new window or tab >>An observational study of activities and multitasking performed by clinicians in two Swedish emergency departments
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2012 (English)In: European journal of emergency medicine, ISSN 0969-9546, E-ISSN 1473-5695, Vol. 19, no 4, p. 246-251Article in journal (Refereed) Published
Abstract [en]

Objectives: To explore the type and frequency of activities and multitasking performed by emergency department clinicians.

Methods: Eighteen clinicians (licensed practical nurses, registered nurses and medical doctors), six from each occupational group, at two Swedish emergency departments were followed in their clinical work for 2 h each to observe all their activities and multitasking practices. Data were analysed using qualitative and quantitative content analysis.

Results: Fifteen categories of activities could be identified based on 1882 observed activities during the 36 h of observation. The most common activity was information exchange, which was most often performed face-to-face. This activity represented 42.1% of the total number of observed activities. Information exchange was also the most common activity to be multitasked. Registered nurses performed most activities and their activities were multitasked more than the other clinicians. The nurses’ and doctors’ offices were the most common locations for multitasking in the emergency department.

Conclusion: This study provides new knowledge regarding the activities conducted by clinicians in the emergency department. The most frequent activity was information exchange, which was the activity most often performed by the clinicians when multitasking occurred. Differences between clinicians were found for activities performed and multitasked, with registered nurses showing the highest frequencies for both.

Place, publisher, year, edition, pages
London: Chapman & Hall, 2012
Keywords
activities; Emergency Service hospital; medical errors; multitasking; nurse clinicians; observations; patient safety; physicians
National Category
Nursing
Research subject
Health and Welfare, ”Många bollar i luften” – Personalens arbetsmiljö på akutmottagning.
Identifiers
urn:nbn:se:du-5745 (URN)10.1097/MEJ.0b013e32834c314a (DOI)000305896600009 ()21934505 (PubMedID)2-s2.0-84863580012 (Scopus ID)
Available from: 2011-08-31 Created: 2011-08-31 Last updated: 2021-11-12Bibliographically approved
3. Interruptions in emergency department work: an observational and interview study
Open this publication in new window or tab >>Interruptions in emergency department work: an observational and interview study
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2013 (English)In: BMJ Quality and Safety, ISSN 2044-5415, E-ISSN 2044-5423, Vol. 22, no 8, p. 656-663Article in journal (Refereed) Published
Abstract [en]

Objectiv.e Frequent interruptions are assumed to have a negative effect on healthcare clinicians’ working memory that could result in risk for errors and hence threatening patient safety. The aim of this study was to explore interruptions occurring during common activities of clinicians working in emergency departments.

Method. Totally 18 clinicians, licensed practical nurses, registered nurses and medical doctors, at two Swedish emergency departments were observed during clinical work for 2 h each. A semistructured interview was conducted directly after the observation to explore their perceptions of interruptions. Data were analysed using non-parametric statistics, and by quantitative and qualitative content analysis.

Results. The interruption rate was 5.1 interruptions per hour. Most often the clinicians were exposed to interruptions during activities involving information exchange. Calculated as percentages of categorised performed activities, preparation of medication was the most interrupted activity (28.6%). Face-to-face interaction with a colleague was the most common way to be interrupted (51%). Most common places for interruptions to occur were the nurses’ and doctors’ stations (68%). Medical doctors were the profession interrupted most often and were more often recipients of interruptions induced by others than causing self-interruptions. Most (87%) of the interrupted activities were resumed. Clinicians often did not regard interruptions negatively. Negative perceptions were more likely when the interruptions were considered unnecessary or when they disturbed the work processes.

Conclusions. Clinicians were exposed to interruptions most often during information exchange. Relative to its occurrence, preparation of medication was the most common activity to be interrupted, which might increase risk for errors. Interruptions seemed to be perceived as something negative when related to disturbed work processes.

National Category
Health Sciences
Research subject
Health and Welfare, ”Många bollar i luften” – Personalens arbetsmiljö på akutmottagning.
Identifiers
urn:nbn:se:du-12694 (URN)10.1136/bmjqs-2013-001967 (DOI)000323166100007 ()2-s2.0-84880888720 (Scopus ID)
Available from: 2013-07-02 Created: 2013-07-02 Last updated: 2021-11-12Bibliographically approved
4. Associations between crowding and ten-day mortality among patients allocated lower triage acuity levels without need of acute hospital care on departure from the emergency department
Open this publication in new window or tab >>Associations between crowding and ten-day mortality among patients allocated lower triage acuity levels without need of acute hospital care on departure from the emergency department
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2019 (English)In: Annals of Emergency Medicine, ISSN 0196-0644, E-ISSN 1097-6760, Vol. 74, no 3, p. 345-356Article in journal (Refereed) Published
Abstract [en]

STUDY OBJECTIVE: We describe the association between emergency department (ED) crowding and 10-day mortality for patients triaged to lower acuity levels at ED arrival and without need of acute hospital care on ED departure.

METHODS: This was a registry study based on ED visits with all patients aged 18 years or older, with triage acuity levels 3 to 5, and without need of acute hospital care on ED departure during 2009 to 2016 (n=705,699). The sample was divided into patients surviving (n=705,076) or dying (n=623) within 10 days. Variables concerning patient characteristics and measures of ED crowding (mean length of stay and ED occupancy ratio) were extracted from the hospital's electronic health records. ED length of stay per ED visit was estimated by the average length of stay for all patients who presented to the ED during the same day and shift and with the same acuity level. The 10-day mortality after ED discharge was used as the outcome measure. Multivariable logistic regression analyses were conducted.

RESULTS: The 10-day mortality rate was 0.09% (n=623). The event group had larger proportions of patients aged 80 years or older (51.4% versus 7.7%) and triaged with acuity level 3 (63.3% versus 35.6%), and greater comorbidity (age-combined Charlson comorbidity index median interquartile range 6 versus 0). We observed an increased 10-day mortality for patients with a mean ED length of stay greater than or equal to 8 hours versus less than 2 hours (adjusted odds ratio 5.86; 95% confidence interval [CI] 2.15 to 15.94) and for elevated ED occupancy ratio. Adjusted odds ratios for ED occupancy ratio quartiles 2, 3, and 4 versus quartile 1 were 1.48 (95% CI 1.14 to 1.92), 1.63 (95% CI 1.24 to 2.14), and 1.53 (95% CI 1.15 to 2.03), respectively.

CONCLUSION: Patients assigned to lower triage acuity levels when arriving to the ED and without need of acute hospital care on departure from the ED had higher 10-day mortality when the mean ED length of stay exceeded 8 hours and when ED occupancy ratio increased.

National Category
Health Sciences
Research subject
Research Profiles 2009-2020, Health and Welfare
Identifiers
urn:nbn:se:du-30483 (URN)10.1016/j.annemergmed.2019.04.012 (DOI)000482210700011 ()31229391 (PubMedID)2-s2.0-85067334196 (Scopus ID)
Available from: 2019-06-27 Created: 2019-06-27 Last updated: 2021-11-12Bibliographically approved

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Berg, Lena M

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