The emergency department receives and processes patients at an unpredictable volume and arrival pattern. The patients present with a range of illnesses and injuries. There may be significant time constraints to evaluate and disposition patients. High-risk procedures are performed at unplanned times. There is a need to constantly adjust and adapt to a changing clinical environment.

There are variable patterns of support staffing in the emergency department and with the hospital medical staff that can disrupt a provider’s actions and thought processes.¹ These interruptions can translate to medical errors and adverse events, which can lead to unwanted stress and inefficiencies for the provider.^2-6 In addition to this, the implementation of computerized physician order entry requires the physician to interact with a computer at an estimated burden of 4,000 keystrokes per 10-hour shift.⁷

Workstations for physicians and advanced practice providers (APPs), to date, have not been tailored to the increasingly digitized workspace, nor to the providers’ needs. The physician and APP workspace should consider comfort and efficiency, with a primary design objective to improve quality and patient safety. A secondary outcome is likely to be a positive effect on provider satisfaction.

Various medical specialties already accomplish this. Radiologists have the appropriate lighting, dictation system, and computer screens to do their job correctly. In the operating room, all equipment is prepped in advance for surgeons to execute their work.

The authors did a convenience polling of several hundred emergency medicine providers at a leadership symposium. Emergency physicians and APP’s were asked which aspect of the clinical work environment would benefit the most from redesign. About 300 EM providers were given the following options: a comfortable and efficient workspace, decreasing the number of interruptions, a private/quiet retreat for documentation and personal use, or having meals and snacks available.

Survey results found the number one improvement providers would like to see in their on-shift clinical environment was a comfortable and efficient workspace, with 41 percent of the votes. The second most commonly selected, 35 percent of responses polled, was to decrease the amount of interruptions. Lower preferences were to have meals/snacks available, followed by a private space for work and personal use, with 16 percent and 8 percent of responses, respectively.

Further polling proposed the question of what EM providers felt was most helpful to decrease interruptions during their shifts. Options included: a desktop messenger system to communicate with all staff, a HIPAA-compliant cell phone app for texting, a physical indicator at the workstation to signal when a provider is busy, or portable computers for bedside use. The top answer was a desktop messenger system (39 percent), followed by a cell phone app (32 percent). A lower percentage of providers opted for the workstation indicator signal and bedside computer (16 percent and 12 percent, respectively).

Providers in the emergency department deal with interruptions on a more frequent basis than other specialties. Interruptions addressed in the poll occur when providers need to divert attention to respond to staff or patient requests, interpret ECGs, answer phone consults, listen to EMS communications, and a variety of other tasks. A study by Chisholm et al found that emergency physicians were interrupted 9.7 times an hour, compared to 3.9 times an hour for primary care physicians.⁸ Other studies have shown that emergency practitioners average about 10 interruptions an hour.^1,9 These interruptions will ultimately reduce the efficiency and produce stress for clinicians.⁶ Despite emergency providers’ skills in multitasking, interruptions reduce efficiency and open the door to errors in documentation and order placement.

There are additional elements that cause unneeded stress in the work environment. The workstation is the site of work performed for an estimated 44 percent of the shift, and with the introduction of mandatory clinical information systems, the computers are the operational cockpit for the physician and APP.⁷

 Provider-Focused Workstation Design

A critical first step to improve the provider environment is ergonomic and functional workstation design. Ideally, a provider workstation would be located near the nurses’ station, but not at a location that results in frequent interruptions. The current state is with a flexible height chair or stool, bare walls, and drop ceilings with non-absorptive materials, making audio privacy almost impossible. Reference materials are taped or pinned to the walls, and a phone is somewhere, but without a fitted headpiece.

The actual “desks” or counter space are not conducive to good work or even good health. Some emergency departments don’t even have dedicated desks for physicians.

Optimally, there should be dedicated workstations appropriate for the number of providers who are working at the busiest times. The workstations would have user-flexible features from counter to desk height and computer screens and keyboards adjustable to ergonomic positions.

Seating options should include flexible height and comfortable stools for seating. Ergonomic seating must support clinician joints in a natural and neutral position. Both the chair and desk should be adjustable to a height and position of optimal comfort. DeRango et al noted that ergonomic chairs improved productivity, in addition to reducing pain scores.¹⁰

The workstation needs a set of wall-mounted computer screens that provide the clinician with a view of the tracking board; the radiologic imaging system; system status of the ED, hospital, and EMS; and any necessary external feeds (risk management, reference materials, weather, news briefs, old ECG’s, telehealth, and special events). Many of these could be on shared screens for all providers in that work area. However, each provider needs a dedicated work computer for patient management.

The workstation needs climate control and 24-hour variable lighting to accommodate the variety of providers who work that area. This space should allow for snacks and drinks. A good workstation will make the physician’s work and patient interaction more professionally satisfying. It would also facilitate a better work environment, less physical stress, and more use of computer assistance for improved quality of care and risk mitigation.

Communication Systems

An asynchronous communication channel is one where each party is contributing at different times, as opposed to a synchronous channel, which is direct, in person communication in which the information is being shared real-time. Integration of an electronic messaging system within the emergency department is an example of an asynchronous communication channel.

In an emergency department, synchronous interruptions regularly affect the emergency physician. Ratwani et al found that 75.4 percent of interruptions resulted in providers leaving their current task to address an interruption.¹² The urgency may or may not directly correlate with the importance of the interruption. The integration of asynchronous interruptions with electronic messaging software may disrupt the timeliness of responses.

Both synchronous and asynchronous ED communication systems would be of value to prevent a negative effect on patient care. Many situations will still arise where staff must communicate immediately and directly with the clinician for an urgent response. However, the importance of reducing non-emergent interruptions is necessary when promoting physician and APP effectiveness.

Many providers report satisfaction and efficiency through using a secure, electronic messaging system as a platform for communication. There are several brands that offer a secure, confidential, and HIPAA-compliant messaging system. A program can run in the background of the desktop that relays information between staff and providers but allows an individual provider to concentrate on a single task at a time. Many of these messaging systems also allow ECGs and radiologic images to be transmitted to consultants.

Communication tools should have input and listening components fitted to each provider. There may be a broad array of phones, radios, and telehealth devices for provider use. The workstation should be lined with surfaces that are noise absorbing so that dictation and physician-to-physician conversations can occur while respecting privacy.

Some modalities are available through mobile phone applications. Accessibility to other staff eases stress on all involved and is more useful in addressing urgent patient needs efficiently. A separate study demonstrated that messaging media, such as an electronic whiteboard, can reduce the number of interruptions that are experienced at the workstation.¹¹ Regardless of the platform chosen, the goal to decrease interruptions by implementing a better communication model between staff members would benefit all involved.⁵

Conclusion

Emergency physicians’ and APPs’ practice styles are as variable as the departments in which they work. A unifying factor is that emergency practitioners need a comfortable and efficient workspace with a more streamlined communication system that maintains their focus. Interruptions and poorly designed work areas add unnecessary tension. Provider queries suggest that a refined work area geared toward optimal clinician health and an effective environment for interacting with the digital health record and other electronic inputs would result in a more effective patient care environment.

References

1. Chisholm CD, Collison EK, Nelson DR, et al. Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”? Acad Emerg Med. 2000;7(11):1239-1243.
2. Gladstone J. Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital. J Adv Nursing. 1995;22(4):628-637.
3. Leape LL. Errors in medicine. 1994;272(23):1851-1857.
4. Grundgeiger T, Sanderson P. Interruptions in healthcare: theoretical views. Int J Med Inform. 2009;78(5):293-307.
5. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. National Academies Press, Washington, DC. 2000.
6. Morrison JB, Rudolph JW. Learning from accident and error: avoiding the hazards of workload, stress, and routine interruptions in the ED. Acad Emerg Med. 2011;18(12):1246-1254.
7. Hill RG, Sears LM, Melanson SW. 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. Am J Emerg Med. 2013;31(11):1591-1594.
8. Chisholm CD, Dornfeld AM, Nelson DR, et al. Work interrupted: comparison of workplace interruptions in emergency departments and primary care offices. Ann Emergency Med. 2001; 38(2):146-151.
9. Brixey JJ, Robinson DJ, Turley JP, et al. The roles of MDs and RNs as initiators and recipients of interruptions in workflow. Int J Med Information. 2010;79(6):e109-115.
10. De Rango K, Amick B, Robertson T, et al. The productivity consequences of two ergonomic interventions. Upjohn Institute Working Paper No. 03-95. Kalamazoo, MI: W.E. Upjohn Institute for Employment Research. 2003.
11. France DJ, Levin S, Hemphill R, et al. Emergency physicians’ behaviors and workload in the presence of an electronic whiteboard. Inter J Medl Inform. 2005;74(10):827-837.
12. Ratwani et al. Emergency physician use of cognitive strategies to manage interruptions. Ann Emerg Med. 2017;70(5):683-687.

Dr. Lim is medical director of the emergency department at Northeast Baptist Hospital in San Antonio, Texas. Ms. Mosinski is lead emergency department advanced practice provider at St. Vincent Hospital in Erie, Pennsylvania. Dr. Perfetti is associate director of the emergency department at AdventHealth Tampa in Tampa, Florida. Ms. Powers is APP system lead in the emergency department at Lawrence + Memorial Hospital/Yale New Haven Health in New London, Connecticut. Dr. Augustine is chair of the National Clinical Governance Board of US Acute Care Solutions, in Canton, Ohio; clinical professor of emergency medicine at Wright State University in Dayton, Ohio; vice president of the Emergency Department Benchmarking Alliance; and a member of the ACEP Board of Directors.