CLINICAL
CAUSES
AND
OCCURRENCES OF INTERRUPTIONS DURING ED TRIAGE
Authors: Kimberly D. Johnson, PhD, RN, CEN, Michele Wargo, MBA, BSN, RN, CCRN, CEN, Dean Gray, MBA, and Connie Kuehn, RN, Cleveland, OH
Introduction: Interruptions have been shown to cause errors and delays in the treatment of emergency patients and pose a real threat during the triage process. Missteps during the triage assessment can send a patient down the wrong treatment path and lead to delays. The purpose of this project was to identify the types and frequency of interruptions during the ED triage interview process. Methods: A focus group of emergency nurses was organized to identify the types of interruptions that commonly occur during the triage interview. These interruptions would be validated through observations in triage. A tally sheet was developed and implemented to determine how often each interruption occurred during an 8-hour shift. Triage nurses completed the tally sheets while working the first shift (7 AM to 3 PM). This shift was selected because patient intake in the US Department of Veterans Affairs Emergency Department is highest during this time. Results: The categories of interruptions identified included provision of conveniences to visitors, coworker-related interruptions, patient care–related interruptions, locating of family members in the emergency department, and other miscella-
Kimberly D. Johnson, Member, Eastern Ohio Chapter, is Postdoctoral Fellow and VA Quality Scholar, Louis Stokes Cleveland VA Medical Center & Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH. Michele Wargo, Member, Cleveland Chapter, is Nurse Manager, Emergency Department, Louis Stokes Cleveland VA Medical Center, Cleveland, OH. Dean Gray is Process Improvement Consultant, Clear Insights LLC, Cleveland, OH. Connie Kuehn is Staff Nurse, Emergency Department, Louis Stokes Cleveland VA Medical Center, Cleveland, OH. For correspondence, write: Kimberly D. Johnson, PhD, RN, CEN, Louis Stokes Cleveland VA Medical Center & Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 4410; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767/$36.00 Copyright © 2013 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2013.06.019
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neous interruptions. Tally sheets were completed by the triage nurses during 10 shifts. On average, triage nurses were interrupted 48.2 times during an 8-hour shift (7 interruptions per hour). After reviewing the data, we found that only 22% of interruptions were related to patient care. More frequently, the causes of interruptions were not related to patient care: opening the door (33%), providing conveniences to visitors (21%), waiting patients or family members asking “How much longer?” (14%), and other causes (10%). Discussion: Frequent interruptions can interfere with concentration and may affect patient care. Non–patient care–related interruptions not only can be frustrating to the triage nurse but also can be offensive to triage patients; they ultimately delay care and may even affect the quality of care. However, because scarce research is available regarding interruptions during ED triage, the effects on patient outcomes are unclear. Additional research needs to be conducted to explore the causes and effects of interruptions to the triage process. Key words: Emergency department; Emergency nursing; Interruptions; Triage
patient’s entry into the health care system often begins in the ED triage. The triage interview process is the critical beginning of the treatment experience for patients entering any emergency department. An emergency triage nurse’s first assessment of a patient is a critical step in an episode of care and can be a good indicator of how an interaction will progress. An incorrect triage decision, missed symptom, incomplete assessment, or unasked question could potentially delay care, resulting in significant morbidity or death. Patients who seek treatment for an injury or acute illness may have their initial triage interview interrupted for myriad reasons (eg, other patients’ needs, visitors’ needs, or staff needs). Interruptions in the triage process cause distractions that can create delays in moving patients into a treatment area, distract nurses from collecting appropriate triage data, or cause the nurse to make a poor triage decision. 1 Errors during triage may adversely affect patient outcomes and decrease quality of care. In addition, they can cause patients to feel devalued and vulnerable, with their
A
WWW.JENONLINE.ORG
1
CLINICAL/Johnson et al
private health issues exposed to the interrupter. Furthermore, interruptions have been shown to adversely affect nurses’ job satisfaction and may lead to burnout for experienced emergency nurses. 2 The nature of the emergency department, where the unexpected is always a possibility, makes interruptions more likely to occur. Until recently, there was a lack of information about the causes and effects of interruptions in the emergency department. The public became more aware of issues that ED practitioners face each day after the release of the 2006 Institute of Medicine report, “Hospital-Based Emergency Care: At the Breaking Point.” 3 This report discussed the problems of interruptions and distractions and the battle to provide high-quality care to ED patients. One potential obstacle in providing high-quality patient care may be that interruptions are intrinsic to the ED environment. Interruptions have been shown to occur more often in emergency care than in other settings. 4 In addition, interruptions of ED providers have been linked to errors and delays in patient care. 5 However, most studies focus on emergency physicians, not emergency nurses. 6–8 Interruptions have also been studied in nursing but focus mainly on inpatient care units. Similar to studies on interruptions of emergency physicians, interruptions of floor nurses administering medications have also been linked to medical errors. 9,10 A study by Kalisch and Aebersold 10 reported that 1,354 interruptions occurred in 136 hours, with 200 errors noted during this time. However, little research has been conducted on how emergency nurses are affected by interruptions because only a few studies have focused on emergency nursing. Brixey et al 6 studied interruptions in workflow for both physicians and nurses at a level 1 trauma center and reported that 16.45% of tasks performed by emergency nurses were interrupted. However, only 1 study could be located that included an assessment of interruptions in triage. 11 Although the triage nurse is part of the emergency department, the triage nurse’s role is very different from the rest of the department. During the 5- to 10-minute triage time, the RN is expected to gather all the information necessary to make an accurate decision regarding the need for and timing of medical intervention. One study found that 13% of triage interviews were interrupted. 11 However, a study by Geraci and Geraci 12 reported that non-primary triage functions interrupted the triage process of over half of all patients (54%) and was linked to significantly longer wait times for patients with higher acuity. This project was initiated because the emergency nurses at the Louis Stokes Cleveland US Department of Veterans Affairs (VA) Medical Center believed that the triage process was too lengthy. Their perception was that unnecessary
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JOURNAL OF EMERGENCY NURSING
interruptions created delays in the triage process. Because the triage nurses were frequently overwhelmed by the numbers of patients needing triage, as well as other requests for service and assistance, a second RN was added to triage during peak hours. Despite this intervention, the nurses voiced concerns about frequent interruptions, compromised patient safety and privacy, and increased stress levels for the nurses. The nurses believed that decreasing the number of interruptions would allow them to triage patients both more accurately and more efficiently. Therefore the aims of this project were to identify frequent causes of interruptions to the triage nurse and to determine how often triage interruptions occur. Methods
This work was performed as a quality-improvement project and was part of a larger initiative to improve the ED processes at the medical center. SETTING
The setting is a single VA hospital emergency department with 12 acute care rooms and 6 “fast-track” rooms for nonacute patients. The emergency department serves approximately 25,000 adult veteran patients annually; it does not serve pediatric patients. The majority of patients are assigned an Emergency Severity Index score of 3, and patient diagnoses vary, including congestive heart failure, acute myocardial infarction, hypertension, stroke, diabetic complications, rashes, and pain issues. Triage is conducted by experienced and triage-trained registered nurses. There are 2 dedicated triage offices, the second generally being opened only in cases of excessive patient check-in numbers. The triage nurse routinely performs a “nurse first” interview when the patient first arrives, followed by a more complete triage soon thereafter. The triage area is secured, so the triage nurse is responsible for opening the door for a visitor or non-ED staff. The entrance to the emergency department and triage office/registration in this setting is a busy entrance and is a thoroughfare to the main hospital. The ED waiting room is located across from triage, with the main thoroughfare passing through it. The triage nurse can view the waiting room through a window in the triage room. DATA COLLECTION
After several iterations, not described in this article, a process map was created by the group and approved by the department leadership. The team discussed what activities should be listed as an interruption. It was determined that
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Johnson et al/CLINICAL
TABLE 1
Number of occurrences, means, and standard deviations for all categories and subcategories of interruptions Category
Subcategory
Opening door
For staff For family Other Total for category Asking persons to stand back—privacy Phone Directions Appointment information Changing television channel Requesting forms Calling cab Weight/blood pressure checks Food/water Other Total for category Perform electrocardiograms Registration folders to rack Take patient back to emergency department Other Total for category Veteran drivers asking for disposition of veteran Locate family member Direct admissions issues Coworker (non–patient care–related interruption) Total for category
Provision of conveniences to visitors
Patient care related
Other
Patients asking “How much longer?” Total for all categories
any activity that required the triage nurse to turn his or her attention away from the patient being triaged or any activity that required the nurse to leave the triage area would be classified as an interruption. The team then developed a tally sheet to capture each occurrence of interruption and also document the cause of each interruption during the triage process. Because no previous list of interruptions specific to triage could be located within the literature, our list was compared with interruptions reported previously in ED settings. 6 No additional potential interruption types were identified based on the available literature. The tally sheet was reviewed by the team, and consensus was reached
■
■ • ■
Total
Mean
SD
77 69 12 166 22
7.7 6.9 1.2 16.6 2.2
5.2079 1.969207 1.813529 6.65332 3.155243
5 20 17 1 2 0 13 24 29 132 21 10 23
0.5 2 1.7 0.1 0.2 0 1.3 2.4 2.9 13.2 2.1 1 2.3
0.971825 1.333333 2.057507 0.316228 0.421637 0 1.567021 1.837873 2.601282 5.711587 3.107339 2.211083 4.347413
23 81 6
2.3 8.1 0.6
1.888562 7.06242 1.074968
22 4 17
2.2 0.4 1.7
2.529822 0.699206 3.267687
49 71
4.454545 7.1
5.520211 8.089087
499
on potential interruptions to include on the data collection sheet (Table 1). The triage nurses then used the tally sheets to record when interruptions occurred by placing hash marks next to specific interruptions. The documented interruptions reflected any and all triage interruptions caused by ED staff, patients, visitors, or non-ED VA employees. Data were gathered only during day shifts (7 AM to 3 PM) for the convenience of the staff RN data collectors and because the major volume of patients are triaged during this time frame. Nurses tracked interruptions on 10 selected days during March and June 2012. It was believed that 10 days would be adequate to determine the broad categories of
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120 100 80 60 40 20 0 Mon
Tues
Wed
Thurs
Tues
Wed
Thurs
Fri
Mon
Tue
FIGURE 1 Total interruptions per shift.
interruptions and how often they were occurring. After all data were collected, the group reconvened to discuss whether the tally sheets adequately captured the interruptions that had occurred or whether changes were required.
Results
The tally sheets were completed by 3 triage nurses during 10 shifts. Data collected showed a total of 499 interruptions in the test period. On average, the triage nurses interacted with 80 patients each day. A mean of 49.9 interruptions occurred per 8-hour shift. The number of interruptions per shift ranged from 20 to 110, with a median of 48. A mean of 6.97 interruptions occurred per hour during an 8-hour shift. Figure 1 depicts the total number of interruptions per day. Table 1 shows the total number of occurrences, means, and standard deviations for all categories and subcategories of interruptions. On average, the triage nurses were interrupted 16.6 times per shift to open the door to the emergency department, whereas providing conveniences to visitors (eg, directions, phone access, and changing the television station) averaged 10.2 interruptions per shift. Patient care–related interruptions that required the triage nurse to physically leave the triage area occurred 8.1 times per shift. Triage nurses were interrupted by patients inquiring how much longer they had to wait to be seen in the emergency department 7.1 times per shift. As shown in Figure 2, granting access to family members and non-ED staff accounted for 33.2% of the total interruptions and was the most significant source of interruptions, occurring 166 times. For the second most
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JOURNAL OF EMERGENCY NURSING
common interruption, providing conveniences to visitors, there were 132 occurrences (26.3%). This category consisted of interactions such as offering directions and appointment information to non-ED patients and visitors, asking patients to stand back while others were discussing confidential matters, and “waiting room management,” which involved issues such as changing the television channel. Patient care–related interruptions, the third most common interruption, occurred 81 times (16.3%), consisting of tasks requiring the triage nurses to leave the triage area (eg, move patients into ED rooms or perform electrocardiograms in a separate room). These tasks are often performed by other staff members, but sometimes the triage nurse is required to perform these duties. Questions such as “How much longer?” ranked fourth among interruption categories and occurred 71 times (14.3%). The final general category of interruptions was “other.” This category included issues with direct admission patients, location of family members, non–patient care–related coworker interruptions, and hired drivers who were looking for the passengers they were to transport. Interruptions in this category occurred 49 times (9.9%). The nurses were accurate in their predictions about what were the most common causes of interruptions for triage nurses. After data collection and debriefing, no additional categories were added to the list of interruptions.
Discussion
Interruptions are common among nurses, and the fast-paced environment of the emergency department makes providers even more susceptible to frequent interruptions. The
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Johnson et al/CLINICAL
Nunber of Interruptions
180 160 140 120 100 80 60 40 20 0 Opening Door
Convenience to visitor
Patient care related
Asking "How much longer"
other
Categories
FIGURE 2 Cause of triage interruptions.
nursing staff identified interruptions as a source of stress and dissatisfaction for the triage nurses in the department. Because there is scarce research on interruptions in triage, the team was required to determine whether the definition of an interruption used in other ED studies is the same as the definition of an interruption used in triage settings. Our definition of an interruption was very broad: any activity that required the triage nurse to turn his or her attention away from the patient being triaged or any activity that required the nurse to leave the triage area. Because some equipment (eg, electrocardiography machine) is located outside of the triage area, activities that are generally considered part of the triage nurse’s role were considered interruptions. We thought that it was necessary to include these interruptions because they impacted flow. As with any emergency department, there was some variability in the number of patients arriving on different days of the week. For the days during which data were collected at our facility, the number of patients triaged ranged from 64 to 97. However, there was no significant relationship between the number of patients and the number of interruptions. The lack of relationship may be because of the small number of days sampled. Additional research needs to be conducted to determine whether a relationship is present. There were significantly more interruptions on day 3, a Wednesday, than on the other days. There are several reasons why there was a significant increase in interruptions for this day. The first possibility is that the patient wait times were longer on this day than any of the other days, so there were more interruptions (n = 27) of patients asking “How much longer?” In addition, it was noted on the data
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collection sheet that the resident physician responsible for treating fast-track patients was responsible for multiple interruptions. Finally, the lack of an ED waiting room greeter/volunteer may have contributed to the higher number of interruptions. In reviewing the data, we found that on the 2 days that had more than 60 interruptions during a shift, there were no ED waiting room volunteer/greeters present. On the days when there were no patient care–related interruptions or patients asking “How much longer?,” there were an ED waiting room volunteer/greeter present for the shift. Although volunteers/greeters may be viewed as barriers, because they may ask questions of the triage nurse, they may also assist in improving patient flow into the department and eliminate distractions and unnecessary interruptions for the triage nurse. Our results show that the triage nurse is often interrupted during private patient interviews. The impact of these interruptions is unknown as of yet. Through experience, it is suspected that patients may feel devalued when their triage interview is interrupted frequently. It is not known how frequent interruptions affect the triage nurse’s concentration, ability to return to the task that he or she was performing, accuracy of acuity assignment, or ability to conduct a thorough assessment. Although the occurrence of interruptions in this study is less than that reported by Clifford-Brown et al, 11 it is important to recognize that interruptions occur frequently in triage. However, the critical thinking involved in triaging patients could be compared with that required of pilots or emergency physicians, about whom studies exist, and such studies have shown the adverse effect of interruptions on
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CLINICAL/Johnson et al
concentration, returning to a task, and avoiding errors. 3,5–7,9,13 Although the impact of interruptions on cognition and memory is well documented among pilots, office workers, physicians, and nurses, 13 the link among interruptions, accuracy, and critical thinking has not been explored in the triage environment. Limitations
The main limitation of this study was that the triage nurses were responsible for recording when interruptions occurred. Therefore it is possible that some interruptions were missed, and the act of documenting the interruption may very well have constituted an interruption. Other limitations are the small number of days when data were collected and the collection of data at a single institution during a single shift. Although our data showed common and consistent categories of interruptions, we do not know whether these categories hold true for weekends, for off-shifts, or at other facilities. Next steps
Identifying the types and frequencies of interruptions is the first step to developing strategies to reduce interruptions. Future research will focus on evaluating the chosen improvement strategy’s effect on patient flow, nurses’ job satisfaction, and the length of time it takes to accurately triage patients. In the next phase of this project, we plan to look at the amount of time consumed by interruptions and explore the effect that interruptions have on patient outcomes. Additional planned research includes replicating this study in diverse facilities to determine whether the frequencies and types of interruptions are consistent with the results of this study. We plan to expand the sampled days to include weekends, as well as afternoon and night shifts. Future studies could focus on identifying relationships between interruptions and the triage nurse’s ability to return to a task and the triage nurse’s concentration, as well as the effect this has on patient outcomes and perceived quality of care. Exploring the accuracy of the triage and the time it requires to triage a patient would be an appropriate metric to investigate.
interruptions were investigated (ie, operating room, postanesthesia care units, and inpatient medication administration), links have been made that have shown patient care to be adversely affected. There is sparse information on how interruptions in triage affect patients or staff. When one considers the fact that ED triage is the entry into the health care system, this is especially surprising. With the limited information available on the causes and implications of interruptions in ED triage, more research needs to be conducted to explore this phenomenon. The relatively unexplored area of triage interruptions needs further investigation to ensure patient safety and privacy and to ensure that optimal care is being provided for emergency patients. REFERENCES 1. Hogan DE, Lairet J. Triage. In: Hogan DE, Burstein JL, eds., Disaster Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:10-5. 2. Cain C, Haque S. Organizational workflow and its impact on work quality. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality. http://www.ncbi.nlm.nih.gov/books/NBK2638/. Accessed March 4, 2013. 3. Institute of Medicine. Hospital-Based Emergency Care: At the Breaking Point. http://iom.edu/Reports/2006/Hospital-Based-Emergency-CareAt-the-Breaking-Point.aspx. Published 2006. Accessed March 5, 2013. 4. Burley D. Better communication in the emergency department. Emerg Nurse. 2011;19:32-6. 5. Westbrook J, Coiera E, Dunsmuir W. The impact of interruptions on clinical task completion. Qual Saf Health Care. 2010;19:284-9. 6. Brixey J, Robinson D, Turley J, Zhang J. The roles of MDs and RNs as initiators and recipients of interruptions in workflow. Int J Med Inform. 2010;79:e109-15. 7. Chisholm C, Collison E, Nelson D, Cordell WH. Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”? Acad Emerg Med. 2000;7:1239-43. 8. Chisholm C, Dornfeld A, Nelson D, Cordell WH. Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med. 2001;38:146-51. 9. Collins S, Currie L, Patel V, Bakken S, Cimino JJ. Multitasking by clinicians in the context of CPOE and CIS use. Stud Health Technol Inform. 2007;129(pt 2):958-62. 10. Kalisch B, Aebersold M. Interruptions and multitasking in nursing care. Jt Comm J Qual Patient Saf. 2010;36:126-32. 11. Clifford-Brown J, Challen K, Ryan B. What happens at triage: a naturalistic observational study. Emerg Med J. 2009;27:931-3.
Conclusion
12. Geraci E, Geraci T. An observational study of the emergency triage nursing role in a managed care facility. J Emerg Nurs. 1994;20:189-94.
Previous research has shown that interruptions have a negative impact on concentration and perceived quality of care, as well as increasing in error rates. In other studies in which
13. Einstein G, McDaniel M, Williford C, Pagan J, Dismukes R. Forgetting of intentions in demanding situations is rapid. J Exp Psychol Appl. 2003;9:147-62.
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JOURNAL OF EMERGENCY NURSING
■ ■ •
■
CAUSES
AND
OCCURRENCES OF INTERRUPTIONS DURING ED TRIAGE
Authors: Kimberly D. Johnson, PhD, RN, CEN, Michele Wargo, MBA, BSN, RN, CCRN, CEN, Dean Gray, MBA, and Connie Kuehn, RN, Cleveland, OH
Introduction: Interruptions have been shown to cause errors and delays in the treatment of emergency patients and pose a real threat during the triage process. Missteps during the triage assessment can send a patient down the wrong treatment path and lead to delays. The purpose of this project was to identify the types and frequency of interruptions during the ED triage interview process. Methods: A focus group of emergency nurses was organized to identify the types of interruptions that commonly occur during the triage interview. These interruptions would be validated through observations in triage. A tally sheet was developed and implemented to determine how often each interruption occurred during an 8-hour shift. Triage nurses completed the tally sheets while working the first shift (7 AM to 3 PM). This shift was selected because patient intake in the US Department of Veterans Affairs Emergency Department is highest during this time. Results: The categories of interruptions identified included provision of conveniences to visitors, coworker-related interruptions, patient care–related interruptions, locating of family members in the emergency department, and other miscella-
Kimberly D. Johnson, Member, Eastern Ohio Chapter, is Postdoctoral Fellow and VA Quality Scholar, Louis Stokes Cleveland VA Medical Center & Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH. Michele Wargo, Member, Cleveland Chapter, is Nurse Manager, Emergency Department, Louis Stokes Cleveland VA Medical Center, Cleveland, OH. Dean Gray is Process Improvement Consultant, Clear Insights LLC, Cleveland, OH. Connie Kuehn is Staff Nurse, Emergency Department, Louis Stokes Cleveland VA Medical Center, Cleveland, OH. For correspondence, write: Kimberly D. Johnson, PhD, RN, CEN, Louis Stokes Cleveland VA Medical Center & Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 4410; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767/$36.00 Copyright © 2013 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2013.06.019
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■ • ■
neous interruptions. Tally sheets were completed by the triage nurses during 10 shifts. On average, triage nurses were interrupted 48.2 times during an 8-hour shift (7 interruptions per hour). After reviewing the data, we found that only 22% of interruptions were related to patient care. More frequently, the causes of interruptions were not related to patient care: opening the door (33%), providing conveniences to visitors (21%), waiting patients or family members asking “How much longer?” (14%), and other causes (10%). Discussion: Frequent interruptions can interfere with concentration and may affect patient care. Non–patient care–related interruptions not only can be frustrating to the triage nurse but also can be offensive to triage patients; they ultimately delay care and may even affect the quality of care. However, because scarce research is available regarding interruptions during ED triage, the effects on patient outcomes are unclear. Additional research needs to be conducted to explore the causes and effects of interruptions to the triage process. Key words: Emergency department; Emergency nursing; Interruptions; Triage
patient’s entry into the health care system often begins in the ED triage. The triage interview process is the critical beginning of the treatment experience for patients entering any emergency department. An emergency triage nurse’s first assessment of a patient is a critical step in an episode of care and can be a good indicator of how an interaction will progress. An incorrect triage decision, missed symptom, incomplete assessment, or unasked question could potentially delay care, resulting in significant morbidity or death. Patients who seek treatment for an injury or acute illness may have their initial triage interview interrupted for myriad reasons (eg, other patients’ needs, visitors’ needs, or staff needs). Interruptions in the triage process cause distractions that can create delays in moving patients into a treatment area, distract nurses from collecting appropriate triage data, or cause the nurse to make a poor triage decision. 1 Errors during triage may adversely affect patient outcomes and decrease quality of care. In addition, they can cause patients to feel devalued and vulnerable, with their
A
WWW.JENONLINE.ORG
1
CLINICAL/Johnson et al
private health issues exposed to the interrupter. Furthermore, interruptions have been shown to adversely affect nurses’ job satisfaction and may lead to burnout for experienced emergency nurses. 2 The nature of the emergency department, where the unexpected is always a possibility, makes interruptions more likely to occur. Until recently, there was a lack of information about the causes and effects of interruptions in the emergency department. The public became more aware of issues that ED practitioners face each day after the release of the 2006 Institute of Medicine report, “Hospital-Based Emergency Care: At the Breaking Point.” 3 This report discussed the problems of interruptions and distractions and the battle to provide high-quality care to ED patients. One potential obstacle in providing high-quality patient care may be that interruptions are intrinsic to the ED environment. Interruptions have been shown to occur more often in emergency care than in other settings. 4 In addition, interruptions of ED providers have been linked to errors and delays in patient care. 5 However, most studies focus on emergency physicians, not emergency nurses. 6–8 Interruptions have also been studied in nursing but focus mainly on inpatient care units. Similar to studies on interruptions of emergency physicians, interruptions of floor nurses administering medications have also been linked to medical errors. 9,10 A study by Kalisch and Aebersold 10 reported that 1,354 interruptions occurred in 136 hours, with 200 errors noted during this time. However, little research has been conducted on how emergency nurses are affected by interruptions because only a few studies have focused on emergency nursing. Brixey et al 6 studied interruptions in workflow for both physicians and nurses at a level 1 trauma center and reported that 16.45% of tasks performed by emergency nurses were interrupted. However, only 1 study could be located that included an assessment of interruptions in triage. 11 Although the triage nurse is part of the emergency department, the triage nurse’s role is very different from the rest of the department. During the 5- to 10-minute triage time, the RN is expected to gather all the information necessary to make an accurate decision regarding the need for and timing of medical intervention. One study found that 13% of triage interviews were interrupted. 11 However, a study by Geraci and Geraci 12 reported that non-primary triage functions interrupted the triage process of over half of all patients (54%) and was linked to significantly longer wait times for patients with higher acuity. This project was initiated because the emergency nurses at the Louis Stokes Cleveland US Department of Veterans Affairs (VA) Medical Center believed that the triage process was too lengthy. Their perception was that unnecessary
2
JOURNAL OF EMERGENCY NURSING
interruptions created delays in the triage process. Because the triage nurses were frequently overwhelmed by the numbers of patients needing triage, as well as other requests for service and assistance, a second RN was added to triage during peak hours. Despite this intervention, the nurses voiced concerns about frequent interruptions, compromised patient safety and privacy, and increased stress levels for the nurses. The nurses believed that decreasing the number of interruptions would allow them to triage patients both more accurately and more efficiently. Therefore the aims of this project were to identify frequent causes of interruptions to the triage nurse and to determine how often triage interruptions occur. Methods
This work was performed as a quality-improvement project and was part of a larger initiative to improve the ED processes at the medical center. SETTING
The setting is a single VA hospital emergency department with 12 acute care rooms and 6 “fast-track” rooms for nonacute patients. The emergency department serves approximately 25,000 adult veteran patients annually; it does not serve pediatric patients. The majority of patients are assigned an Emergency Severity Index score of 3, and patient diagnoses vary, including congestive heart failure, acute myocardial infarction, hypertension, stroke, diabetic complications, rashes, and pain issues. Triage is conducted by experienced and triage-trained registered nurses. There are 2 dedicated triage offices, the second generally being opened only in cases of excessive patient check-in numbers. The triage nurse routinely performs a “nurse first” interview when the patient first arrives, followed by a more complete triage soon thereafter. The triage area is secured, so the triage nurse is responsible for opening the door for a visitor or non-ED staff. The entrance to the emergency department and triage office/registration in this setting is a busy entrance and is a thoroughfare to the main hospital. The ED waiting room is located across from triage, with the main thoroughfare passing through it. The triage nurse can view the waiting room through a window in the triage room. DATA COLLECTION
After several iterations, not described in this article, a process map was created by the group and approved by the department leadership. The team discussed what activities should be listed as an interruption. It was determined that
■ ■ •
■
Johnson et al/CLINICAL
TABLE 1
Number of occurrences, means, and standard deviations for all categories and subcategories of interruptions Category
Subcategory
Opening door
For staff For family Other Total for category Asking persons to stand back—privacy Phone Directions Appointment information Changing television channel Requesting forms Calling cab Weight/blood pressure checks Food/water Other Total for category Perform electrocardiograms Registration folders to rack Take patient back to emergency department Other Total for category Veteran drivers asking for disposition of veteran Locate family member Direct admissions issues Coworker (non–patient care–related interruption) Total for category
Provision of conveniences to visitors
Patient care related
Other
Patients asking “How much longer?” Total for all categories
any activity that required the triage nurse to turn his or her attention away from the patient being triaged or any activity that required the nurse to leave the triage area would be classified as an interruption. The team then developed a tally sheet to capture each occurrence of interruption and also document the cause of each interruption during the triage process. Because no previous list of interruptions specific to triage could be located within the literature, our list was compared with interruptions reported previously in ED settings. 6 No additional potential interruption types were identified based on the available literature. The tally sheet was reviewed by the team, and consensus was reached
■
■ • ■
Total
Mean
SD
77 69 12 166 22
7.7 6.9 1.2 16.6 2.2
5.2079 1.969207 1.813529 6.65332 3.155243
5 20 17 1 2 0 13 24 29 132 21 10 23
0.5 2 1.7 0.1 0.2 0 1.3 2.4 2.9 13.2 2.1 1 2.3
0.971825 1.333333 2.057507 0.316228 0.421637 0 1.567021 1.837873 2.601282 5.711587 3.107339 2.211083 4.347413
23 81 6
2.3 8.1 0.6
1.888562 7.06242 1.074968
22 4 17
2.2 0.4 1.7
2.529822 0.699206 3.267687
49 71
4.454545 7.1
5.520211 8.089087
499
on potential interruptions to include on the data collection sheet (Table 1). The triage nurses then used the tally sheets to record when interruptions occurred by placing hash marks next to specific interruptions. The documented interruptions reflected any and all triage interruptions caused by ED staff, patients, visitors, or non-ED VA employees. Data were gathered only during day shifts (7 AM to 3 PM) for the convenience of the staff RN data collectors and because the major volume of patients are triaged during this time frame. Nurses tracked interruptions on 10 selected days during March and June 2012. It was believed that 10 days would be adequate to determine the broad categories of
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120 100 80 60 40 20 0 Mon
Tues
Wed
Thurs
Tues
Wed
Thurs
Fri
Mon
Tue
FIGURE 1 Total interruptions per shift.
interruptions and how often they were occurring. After all data were collected, the group reconvened to discuss whether the tally sheets adequately captured the interruptions that had occurred or whether changes were required.
Results
The tally sheets were completed by 3 triage nurses during 10 shifts. Data collected showed a total of 499 interruptions in the test period. On average, the triage nurses interacted with 80 patients each day. A mean of 49.9 interruptions occurred per 8-hour shift. The number of interruptions per shift ranged from 20 to 110, with a median of 48. A mean of 6.97 interruptions occurred per hour during an 8-hour shift. Figure 1 depicts the total number of interruptions per day. Table 1 shows the total number of occurrences, means, and standard deviations for all categories and subcategories of interruptions. On average, the triage nurses were interrupted 16.6 times per shift to open the door to the emergency department, whereas providing conveniences to visitors (eg, directions, phone access, and changing the television station) averaged 10.2 interruptions per shift. Patient care–related interruptions that required the triage nurse to physically leave the triage area occurred 8.1 times per shift. Triage nurses were interrupted by patients inquiring how much longer they had to wait to be seen in the emergency department 7.1 times per shift. As shown in Figure 2, granting access to family members and non-ED staff accounted for 33.2% of the total interruptions and was the most significant source of interruptions, occurring 166 times. For the second most
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common interruption, providing conveniences to visitors, there were 132 occurrences (26.3%). This category consisted of interactions such as offering directions and appointment information to non-ED patients and visitors, asking patients to stand back while others were discussing confidential matters, and “waiting room management,” which involved issues such as changing the television channel. Patient care–related interruptions, the third most common interruption, occurred 81 times (16.3%), consisting of tasks requiring the triage nurses to leave the triage area (eg, move patients into ED rooms or perform electrocardiograms in a separate room). These tasks are often performed by other staff members, but sometimes the triage nurse is required to perform these duties. Questions such as “How much longer?” ranked fourth among interruption categories and occurred 71 times (14.3%). The final general category of interruptions was “other.” This category included issues with direct admission patients, location of family members, non–patient care–related coworker interruptions, and hired drivers who were looking for the passengers they were to transport. Interruptions in this category occurred 49 times (9.9%). The nurses were accurate in their predictions about what were the most common causes of interruptions for triage nurses. After data collection and debriefing, no additional categories were added to the list of interruptions.
Discussion
Interruptions are common among nurses, and the fast-paced environment of the emergency department makes providers even more susceptible to frequent interruptions. The
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Nunber of Interruptions
180 160 140 120 100 80 60 40 20 0 Opening Door
Convenience to visitor
Patient care related
Asking "How much longer"
other
Categories
FIGURE 2 Cause of triage interruptions.
nursing staff identified interruptions as a source of stress and dissatisfaction for the triage nurses in the department. Because there is scarce research on interruptions in triage, the team was required to determine whether the definition of an interruption used in other ED studies is the same as the definition of an interruption used in triage settings. Our definition of an interruption was very broad: any activity that required the triage nurse to turn his or her attention away from the patient being triaged or any activity that required the nurse to leave the triage area. Because some equipment (eg, electrocardiography machine) is located outside of the triage area, activities that are generally considered part of the triage nurse’s role were considered interruptions. We thought that it was necessary to include these interruptions because they impacted flow. As with any emergency department, there was some variability in the number of patients arriving on different days of the week. For the days during which data were collected at our facility, the number of patients triaged ranged from 64 to 97. However, there was no significant relationship between the number of patients and the number of interruptions. The lack of relationship may be because of the small number of days sampled. Additional research needs to be conducted to determine whether a relationship is present. There were significantly more interruptions on day 3, a Wednesday, than on the other days. There are several reasons why there was a significant increase in interruptions for this day. The first possibility is that the patient wait times were longer on this day than any of the other days, so there were more interruptions (n = 27) of patients asking “How much longer?” In addition, it was noted on the data
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collection sheet that the resident physician responsible for treating fast-track patients was responsible for multiple interruptions. Finally, the lack of an ED waiting room greeter/volunteer may have contributed to the higher number of interruptions. In reviewing the data, we found that on the 2 days that had more than 60 interruptions during a shift, there were no ED waiting room volunteer/greeters present. On the days when there were no patient care–related interruptions or patients asking “How much longer?,” there were an ED waiting room volunteer/greeter present for the shift. Although volunteers/greeters may be viewed as barriers, because they may ask questions of the triage nurse, they may also assist in improving patient flow into the department and eliminate distractions and unnecessary interruptions for the triage nurse. Our results show that the triage nurse is often interrupted during private patient interviews. The impact of these interruptions is unknown as of yet. Through experience, it is suspected that patients may feel devalued when their triage interview is interrupted frequently. It is not known how frequent interruptions affect the triage nurse’s concentration, ability to return to the task that he or she was performing, accuracy of acuity assignment, or ability to conduct a thorough assessment. Although the occurrence of interruptions in this study is less than that reported by Clifford-Brown et al, 11 it is important to recognize that interruptions occur frequently in triage. However, the critical thinking involved in triaging patients could be compared with that required of pilots or emergency physicians, about whom studies exist, and such studies have shown the adverse effect of interruptions on
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concentration, returning to a task, and avoiding errors. 3,5–7,9,13 Although the impact of interruptions on cognition and memory is well documented among pilots, office workers, physicians, and nurses, 13 the link among interruptions, accuracy, and critical thinking has not been explored in the triage environment. Limitations
The main limitation of this study was that the triage nurses were responsible for recording when interruptions occurred. Therefore it is possible that some interruptions were missed, and the act of documenting the interruption may very well have constituted an interruption. Other limitations are the small number of days when data were collected and the collection of data at a single institution during a single shift. Although our data showed common and consistent categories of interruptions, we do not know whether these categories hold true for weekends, for off-shifts, or at other facilities. Next steps
Identifying the types and frequencies of interruptions is the first step to developing strategies to reduce interruptions. Future research will focus on evaluating the chosen improvement strategy’s effect on patient flow, nurses’ job satisfaction, and the length of time it takes to accurately triage patients. In the next phase of this project, we plan to look at the amount of time consumed by interruptions and explore the effect that interruptions have on patient outcomes. Additional planned research includes replicating this study in diverse facilities to determine whether the frequencies and types of interruptions are consistent with the results of this study. We plan to expand the sampled days to include weekends, as well as afternoon and night shifts. Future studies could focus on identifying relationships between interruptions and the triage nurse’s ability to return to a task and the triage nurse’s concentration, as well as the effect this has on patient outcomes and perceived quality of care. Exploring the accuracy of the triage and the time it requires to triage a patient would be an appropriate metric to investigate.
interruptions were investigated (ie, operating room, postanesthesia care units, and inpatient medication administration), links have been made that have shown patient care to be adversely affected. There is sparse information on how interruptions in triage affect patients or staff. When one considers the fact that ED triage is the entry into the health care system, this is especially surprising. With the limited information available on the causes and implications of interruptions in ED triage, more research needs to be conducted to explore this phenomenon. The relatively unexplored area of triage interruptions needs further investigation to ensure patient safety and privacy and to ensure that optimal care is being provided for emergency patients. REFERENCES 1. Hogan DE, Lairet J. Triage. In: Hogan DE, Burstein JL, eds., Disaster Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:10-5. 2. Cain C, Haque S. Organizational workflow and its impact on work quality. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality. http://www.ncbi.nlm.nih.gov/books/NBK2638/. Accessed March 4, 2013. 3. Institute of Medicine. Hospital-Based Emergency Care: At the Breaking Point. http://iom.edu/Reports/2006/Hospital-Based-Emergency-CareAt-the-Breaking-Point.aspx. Published 2006. Accessed March 5, 2013. 4. Burley D. Better communication in the emergency department. Emerg Nurse. 2011;19:32-6. 5. Westbrook J, Coiera E, Dunsmuir W. The impact of interruptions on clinical task completion. Qual Saf Health Care. 2010;19:284-9. 6. Brixey J, Robinson D, Turley J, Zhang J. The roles of MDs and RNs as initiators and recipients of interruptions in workflow. Int J Med Inform. 2010;79:e109-15. 7. Chisholm C, Collison E, Nelson D, Cordell WH. Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”? Acad Emerg Med. 2000;7:1239-43. 8. Chisholm C, Dornfeld A, Nelson D, Cordell WH. Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med. 2001;38:146-51. 9. Collins S, Currie L, Patel V, Bakken S, Cimino JJ. Multitasking by clinicians in the context of CPOE and CIS use. Stud Health Technol Inform. 2007;129(pt 2):958-62. 10. Kalisch B, Aebersold M. Interruptions and multitasking in nursing care. Jt Comm J Qual Patient Saf. 2010;36:126-32. 11. Clifford-Brown J, Challen K, Ryan B. What happens at triage: a naturalistic observational study. Emerg Med J. 2009;27:931-3.
Conclusion
12. Geraci E, Geraci T. An observational study of the emergency triage nursing role in a managed care facility. J Emerg Nurs. 1994;20:189-94.
Previous research has shown that interruptions have a negative impact on concentration and perceived quality of care, as well as increasing in error rates. In other studies in which
13. Einstein G, McDaniel M, Williford C, Pagan J, Dismukes R. Forgetting of intentions in demanding situations is rapid. J Exp Psychol Appl. 2003;9:147-62.
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