Intensity of work in the emergency department

11 Aug

My suspicion is that the ED is the most intense place to work in the hospital. You could probably even substitute “stressful” for “intense”.

I will never prove this and I’m not trying to pull a “woe is us” type moan about how we work much harder than everyone else. The hardest I have ever worked is in the ED, no doubt about it, but this is of course personal anecdote and I’m really not trying to get one up on someone else.

But I do find the way and manner and context in which we work in the ED to be of particular interest.

Take these two studies:

Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”? Acad Emerg Med 2000 Nov.;7(11):1239–1243. PMID 11073472

Coiera EW, Jayasuriya RA, Hardy J, Bannan A, Thorpe MEC. Communication loads on clinical staff in the emergency department. Med. J. Aust. 2002 May;176(9):415–418. PMID 12056992

Basically they followed docs and nurses about the ED and watched what they did and how often they were interrupted and what the interruptions were. These were classified and defined as interruptions not just phone calls and doing different things in the order they were meant to be done.

They both found roughly the same answer. 10 interruptions per hour. Or every 6 minutes if you like.

My anecdotal experience is that it’s probably higher than that, certainly in the UK system with its relative staffing shortages compared to either the US or australasia.

Two thirds of these interruptions led to the doc stopping what they were doing and attending to the new thing.

It is bloody annoying being interrupted every few minutes. Just listen to the juniors on the ward complaining about their pagers going off.

But it is the only way to work. Especially in the ED – all kinds of shit is going off all around you (Though hopefully not this…) and your job is to respond appropriately no matter how annoying it might be.

People who are good at this tend to make good emergency docs. People who are smarter go and do anaesthetics… (in jest honestly…)

I went from doing 5 days a week to 4 days a week when I was 28. I’m now 30 and if I get out of my tweed sweater, patches on sleeves lecturing I’ll try and only go back at 3 or 4 days a week.

ED work is brilliant but boy it’s intense.

UPDATE

Enrico Coeira (one of the main authors on most of the research on this) left a comment below that’s worth checking out along with some additional papers to check out that I’ve reposted here:

Further Reading

Coiera E, Tombs V. Communication behaviours in a hospital setting: an observational study. BMJ 1998 Feb.;316(7132):673–676. PMCID 9522794

Westbrook JI, Coiera E, Dunsmuir WTM, Brown BM, Kelk N, Paoloni R, Tran C. The impact of interruptions on clinical task completion. Qual Saf Health Care 2010 Aug.;19(4):284–289. PMID 20463369

Spencer R, Coiera E, Logan P. Variation in communication loads on clinical staff in the emergency department. Ann Emerg Med 2004 Sep.;44(3):268–273. PMID 15332070

Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med 2010 Apr.;170(8):683–690. PMID 20421552 (free)

 

5 Replies to “Intensity of work in the emergency department

  1. A great and still unappreciated topic – thanks for raising it.

    The level of interruption actually varies strongly clinical role, which make sense as some staff are more likely to be the focus for advice seeking than others:

    R. Spencer, E. Coiera, P. Logan, Variation in Communication Loads on Clinical Staff in the Emergency Department, Annals of Emergency Medicine 2004:44/3,268-273.

    Interestingly in our earliest studies of interruption, despite doctors feeling they were the ones being interrupted all the time, we found doctors initiating more interruptions than they received from nursing staff:

    E. Coiera, V. Tombs, Communication behaviours in a hospital setting – an observational study, British Medical Journal, 316,673-677, (1998).

    In more recent studies we have now started to explore the consequences of interruption on clinical work. Not all interruptions are ‘bad’ but too may can lead to tasks being left incomplete, having less time available to to a task, and significantly lead to errors, for example in administering medications.

    Westbrook J, Coiera E, Dunsmuir W, Brown B, Kelk N, Paoloni R, Tran C. The impact of interruptions on clinical task completion, BMJ Quality & Safety in Health Care 2010 19(4):284-9.

    Johanna I. Westbrook, PhD; Amanda Woods, RN, MEd; Marilyn I. Rob, PhD; William T. M. Dunsmuir, PhD; Richard O. Day, MD Association of Interruptions With an Increased Risk and Severity of Medication Administration Errors. Arch Intern Med. 2010;170(8):683-690.

    Enjoy!

    Enrico

    • Cheers for that Enrico.

      Seeing as you’re leading the research in all this can I ask how the ED compares with other specialties? I presume the interruptions are much more common but I’ve not read much about it

      I’ll also put a reference to those papers in the post so people can have a read at them.

      thanks again

      andy

      • We probably know more about interruptions in ED than anywhere else – its a historical accident that some of us started measuring in ED and others have followed the lead, replicating and extending results.

        My impression is that a busy ED is indeed probably amongst the most interupt-driven places in a hospital, but here are a few pointers to other clinical settings that are surprisingly interruptive:

        1 – ICU ward rounds. Rather than a calm and ordered progression from bed to bed, this is a very interrupted set of competing conversations:

        Alvarez G, Coiera EW (2005) Interruptive communication patterns in the intensive care unit ward round, International Journal of Medical Informatics, vol.74, pp.791-796.

        2 – Surgery is surprisingly interrupted, from doors opening to bleepers going off. General surgery has been shown to have an interruption rate of ~14/case, 0.29/min. Culprits include external staff, equipment, and
        bleeper.

        Healey et al. Ergonomics, 49, 589-604 2006.

        3 – Induction of general anaesthesia for urgent surgical cases you think would be protected time, but one study found 5 interruptions per induction, extending over 40% of induction time. In 22% of the time the impact on induction was “significant”.

        Savoldelli et al. Eur J Anaesth (2010).

        Bottom line – interruption is how we work, and how we get things done. But it has many downsides in terms of safety, quality and efficiency. Not all interruptions are necessary, and as many of the papers explore, simple strategies to replace ‘synchronous’ communication with asynchronous information seeking can help.

        But no one would say that you should not interrupt another when the question you have is both urgent and important. It is a question of mindful balance.

  2. Agree totally about the interruptions – it’s simply the nature of the job and it would in many cases be a bad idea to try and reduce them and cut them out.

    But I think It’s good to know about them for training purposes; people who can multi-task are valuable in the ED!

  3. Pingback: Communication in medicine | Emergency Medicine Ireland

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