The No-Interruption Zone

The following is an example of a typical cockpit to tower communication during landing. Pilot: “Cincinnati Tower, we’re six miles southeast and control VFR.” Tower: “Runway 18, wind 230 degrees, five knots, altimeter 30.” Pilot: “Roger, Runway 18.” Tower: “Have you in sight, cleared to land.” In safety critical industries such as commercial air travel, processes have been put into place to limit interruptions during certain tasks. The “sterile cockpit rule” limits non-essential communication and activities during taxi, takeoff, landing, and flying below 10,000 feet.

In the hectic ED, interruptions and distractions can cause critical errors, even death. Here are five key areas where disruptions need to be eliminated, and practical ways to get there. 

The following is an example of a typical cockpit to tower communication during landing. Pilot: “Cincinnati Tower, we’re six miles southeast and control VFR.” Tower: “Runway 18, wind 230 degrees, five knots, altimeter 30.” Pilot: “Roger, Runway 18.” Tower: “Have you in sight, cleared to land.” In safety critical industries such as commercial air travel, processes have been put into place to limit interruptions during certain tasks. The “sterile cockpit rule” limits non-essential communication and activities during taxi, takeoff, landing, and flying below 10,000 feet.

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What would it be like to apply this same logic to a shift in the emergency department? If you could completely eliminate interruptions at critical moments, would you become more efficient and less error prone? Would you have more time to talk to your patients? While entirely eliminating interruptions in the ED isn’t realistic, how much interruption is OK? How do we minimize interruptions at critical moments in patient care to reduce the chance of error?

Out of the entire healthcare system, emergency physicians probably face the highest number of interruptions per hour.1,2 One study demonstrated an interruption rate of 6.6 times per hour based on direct observation. Doctors failed to return to task 18.5% of those times interrupted.2 Interruptions lead to lapses and slips due to memory recall problems and attention shifts. It has been shown by Westbrook, et al that interrupting nurses during medication administration increased the incidence of procedural failures and clinical errors.3 Clearly, interruptions present a significant patient safety risk.

The financial costs of unnecessary interruptions to the healthcare system have not been studied, however a report released in 2005 which looked at “knowledge workers” in the United States over an 18-month period sheds some light on the issue. After months of interviews and observation, the study concluded that interruptions consume 28% of an employee’s workday and cost U.S. companies an estimated $588 billion per year.4 The cost of interruptions to the healthcare industry are likely even higher. Not only are interruptions more prevalent in the healthcare industry, but salaries are also higher than the $21 per hour estimate used in the study.

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The question then is how can we practically reduce interruptions in the emergency department. It starts by identifying the most critical moments of the patient encounter, coming up with solutions to minimize interruptions, and then learning how to get back on task when necessary interruptions do occur.

H&P

The history and physical is a very important information gathering task that forms the basis of what orders will be needed to evaluate the patient.  These moments are critical, yet are also commonly plagued by interruption. Leaving and returning to the patient during this process can lead to an abbreviated or incomplete history or physical exam. It can also lead to delays in beginning care for that patient. One solution is to establish a “No Interruption Zone” (NIZ) while the physician is in the patient exam room. Phone calls can be held or returned when the exam is complete. Educating staff about this NIZ policy is the key to success. When an emergent interruption is necessary, have a scribe or staff member make a note of where you left off so that you may return to the task at the same point in the H&P.

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CPOE

One of the most critical thought tasks for any patient encounter is placing orders into the electronic medical record. Interruptions during order placement may lead to errors in accuracy, or they can cause the physician to fail to place the orders entirely. I have seen providers interrupted with a phone call who then never went back to complete the order set. Again, establishing an NIZ could be helpful. In fact, CPOE may be the most useful and easy area to establish such a zone. (The nurses and scribes in my department all know not to speak to me during order entry.) You can develop a departmental policy creating this task as a no interruption activity. Again, this must be a team effort; staff education is vital. Need reinforcement? A scribe can be used to have those approaching you pause until the orders are signed.

Results Review

Results review is another thought task where interruption can compromise patient safety. Interruption can lead to failure to appropriately act on results reviewed or cause you to miss a result altogether. Depending on your EMR, it may or may not be easy for co-workers to identify that you are reviewing results. This makes it more challenging to effectively use an NIZ for this task. One solution here would be to use an LED light placed on the top of the monitor that would illuminate during CPOE and results review – sort of like an “On Air” sign at a radio station. This would act as a visual cue to all that a no-interruption zone exists. This would require integration with your EMR vendor, but could ultimately be a low-cost, high yield solution that would benefit the entire healthcare establishment.

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Procedures

Disruptions during procedure preparation and performance are common and be brought on by something as simple as trying to locate a piece of equipment. These distractions can lead to a range of errors, from creating a break in aseptic preparation to failing to complete universal protocols. One solution is the incorporation of checklists, a strategy common to other safety-critical industries such as airline, nuclear and military. Develop a checklist for your department that covers equipment and set up needs for each procedure and use it every time that procedure is done. You can use a scribe, tech or nurse to run through the checklist each time as you prepare. Another practical solution to minimize interruption during a procedure is to only allow essential personnel in the room. We have developed a simple sign system for the exam room door notifying others that a procedure is in progress. In addition, similar to the “sterile cockpit rule” we have eliminated any communication not directly related to the task at hand for the duration of the procedure.

Sign-Out

Bedside sign-out at change of shift is also a period of critical information transfer that should adopt a NIZ approach. The best way to succeed at this is to continually educate your staff, explaining why they shouldn’t intrude on the process. If staff education is not enough, a wearable reminder notifying others you are in sign out could be used. Checklists also work here to make sure all important information has been transferred to the oncoming provider.

Alarm Fatigue

Whether it’s a monitor alarm, the dreaded “pop-up box” in your EMR, overhead pages, or simply loud noise, the ED is an extremely distracting place. Work with your IT department to turn down the annoying warning boxes to the lowest appropriate and safe level. We want to know about the allergy to the medication we just ordered; we do not want to know about the interaction between the ED ketorolac order and the Naprosyn prescription at discharge. Find safe ways to reduce alerts that do not contribute to safety and only add to the risk of alarm fatigue. IT solutions can be implemented to send monitor alarms right to a mobile device of the treating RN which can eliminate the loud audible alarm that grabs everyone’s attention.

A Better Work Atmosphere

Incursions to your attention caused by ambient noise and activity, belligerent patients, and side conversations can also be mitigated by changes to the physical workspace. Simply having a more private protected physician workstation can eliminate these other attention stealers and allow more focus on your tasks. Sitting in the middle of the department with line of sight everywhere is comforting because it allows you to know what is happening, but with patient tracking boards, it is now fairly simple to have a snapshot feel for what is happening in the department without being in the middle of it all.

Appropriate Interruptions

While there are times for necessary interruption such as a crashing patient or a new arrival of a critical patient, for less acute issues, identifying the most appropriate time for interruption should be the goal. Even standing up in the department at an opportune moment and announcing to the staff, “OK, what do you have for me?” can serve as a cue to approach at the most appropriate time. If this is done with frequency and as a habit, it will eventually become the norm in your department.

Knowing the most common causes of interruption in your department and then using policies, staff education, smarter IT, and changes to the physical environment you can decrease the number of interruptions in your department during critical tasks. Where interruptions cannot be avoided, using techniques such as checklists, reminders, post-its and limiting conversation to work tasks can lessen the effects of interruptions.

Continued human factors research should focus on workflow, workspace design, EMR improvements, new IT solutions, communication improvements, and interruption reduction policies in the chaotic emergency department environment.

Jeremy Tucker, DO serves as Regional Medical Director for MEP Health and also as Physician Champion Patient Safety for Medstar St. Mary’s Hospital in Leonardtown, MD.

References

1. Weigl M, Muller A, Vincent C, et al.  The association of workflow interruptions and hospital doctors’ workload: a prospective observational study. BMJ Qual Saf  2012 May; 21(5):399-407.
2. Westbrook J, Coiera E, Dunsmuir W, et al. The impact of interruptions on clinical task completion  Qual Saf Health Care  2010 May; 19:284-289.
3. Westbrook J, Woods A, Rob M, et al.  Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med 2010 Apr 26; 170(8):683-90.
4. “The Cost of Not Paying Attention: How Interruptions Impact Knowledge Worker Productivity,” Jonathan B. Spira and Joshua B. Feintuch, Basex, 2005