October 17th, 2017
Emergency Medicine: A Life of Interruption
Emergency medicine is a life of interruption. Physicians, nurses, PAs, radiology techs, registration clerks: we are all constantly interrupted or interrupting. Unfortunately, interruptions and distractions and the consequent attention shift may lead to error. Sometimes, we fail to return to the original task, make an error in that task, or waste time on less urgent needs, neglecting critical ones.
Learning when to focus and when to ignore a distraction is perhaps one of the most vital skills needed in emergency medicine. Working in the ER can lead to a culture of immediacy; everything is now, yesterday, too late already. But seriously — is it? Just because we want something STAT, does it need to be STAT?
Recently, as part of a course in narrative medicine, I have been studying attention, awareness and mindfulness. I realized as I studied this material that not only is interruption frequent in emergency medicine, it is also widely accepted. Yes, if the patient is moribund, exsanguinating, showing tombstones on his EKG or otherwise in extremis, then interruption is essential and valid. But what about all the other times — the telephone calls, the verbal interruptions, the pages, the side conversations?
- A clerk is on the phone. A doctor asks her to page a specialist.
- A PA is putting orders in on a patient. The triage nurse stops by and asks her to review an EKG.
- A nurse is drawing up meds to give to a patient. A PA interrupts her, asking if she will get discharge vitals on another patient.
- The physician is taking a history. The registration clerk enters the room and asks the patient for insurance information.
- The NP is reviewing imaging. The radiology tech stops by and advises him to order a creatinine on another patient.
- A physician is doing a critical procedure on a patient. A nurse walks in and asks him if she can give Zofran to another patient.
- Two physicians are doing sign-out. The social worker interrupts to discuss a psychiatric admission.
Health care systems researchers have documented interruptions in health care environments, including the relatively high interruption rate in emergency departments compared with primary care. Other evidence supports the observation that, once interrupted, ER providers frequently fail to return to the task. Moreover, attention shifts can lead to procedural errors and incomplete patient orders and evaluations.
Given these risks, could we establish protocols or an etiquette that would reduce the number of distractions and interruptions?
I think we can.
Here are some ways we might start.
First, we could each consider the import of our interruptions – i.e., ask ourselves:
- Do I need to ask this now?
- Does this need immediate attention?
- Provider sign-out
- Nurse medication preparation and administration
- Patient evaluation by medical staff
- Clinician review of labs and imaging
- Putting in orders
- Patient procedures
Such tasks could be designated as protected from non-emergent interruption. ERs might also consider developing protected work stations (areas), limiting phone calls, programming EMR cues, and setting monitor alarms to safe and appropriate levels.
At the individual level, developing awareness is also a tool to mitigate distraction. Awareness requires us to be reflective and notice what does and does not interest us — and to recognize when an attention shift occurs. I am aware that being interrupted or distracted while I am putting in orders can result in a dangerous attention shift. Consequently, I consider this protected time. Unless a critical need arises, I finish these tasks first. Awareness has helped me focus my attention and avoid errors.
Being able to bring back a wandering attention — and knowing it has wandered — is one way each of us can lessen the effects of a chaotic and noisy environment. Other tools that might help are:
- List writing and post it notes
- Limiting off-topic conversations
- Limiting the number of visitors
- Posting “do not disturb” signs during critical procedures
- Limiting cell phone use by patients and their visitors
Interruption reduction is the responsibility of every member of the medical team. As both interrupters and the interrupted, I suggest we start by asking ourselves two simple questions at these moments:
Is this an appropriate time?
Should I delay this interruption?