Interruptions to Clinical Work: How Frequent Is Too Frequent?

Abstract

G iven the stresses and cognitive burden 1–5 imposed by constant interruptions, it is not surprising that one of the latest developments in mobile phone technology is a sophisticated ''interruption'' filter. This filter allows us to screen out all but specified priority callers while we concentrate on the job at hand. Meanwhile, our phones will let everyone else know we are busy. Once we signal we are free, our phones will remind us to deal with missed calls and messages. This is an elegant technologic solution to a common modern-day problem: A solid body of largely experimental evidence links interruptions to critical cognitive failures. These cognitive failures include lapses in attention or memory, impaired decision-making, increased stress and anxiety, and higher error rates. Interrupting someone midtask can lead to short-term memory disruption result-ing in tasks being left unfinished, or they may be hurriedly finished off with corners cut to make up for lost time. 1,4,6 In the aviation industry, interruptions have been associated with major negative events 7 and pose a significant hazard for task errors, so much so that, in 1981, the US Federal Aviation Authority mandated the ''Sterile Cockpit,'' now standard operating procedure on commercial airlines. This means a series of prohibitions come into force in cockpits during critical safety tasks to isolate air crew from interruptions. These prohibitions include a ban on nones-sential conversations. How does this well-established relationship between interruptions and diminished performance and errors play out in busy clinical settings where numerous interruptions to doctors and other staff occur and may be essential to delivery of critical care on time? It is reasonably straight-forward to quantify the rate at which interruptions occur using standardized tools and definitions. 8–10 However, it is considerably more challenging to understand and measure their effect and to identify classes of interruptions, which might be successfully reduced without disrupting commu-nication pathways essential to positive patient outcomes. Currently, this complex but crucial relationship between interruptions and outcomes is poorly understood. 11–13 In this issue of the Journal of Graduate Medical Education, Ly and colleagues 14 add to the growing body of health care research investigating interruptions to health professionals' workflow. They report the results of a direct observational study to measure interruptions to junior medical staff due to pagers. Twenty-four junior medical officers (equivalent to junior residents in the United States) were each observed during 2 days and received 163 page calls, or about 6 to 8 observed calls per resident. Of these pager calls made to the residents, 16% (n 5 26) were judged to be inappropriate, 58% (n 5 95) were appropriate but not urgent, and 27% (n 5 44) were appropriate and urgent. A New Zealand study of 844 pager calls found a very similar distribution among these categories. 15 These results confirm that many interruptions to clinical work are necessary and are, in themselves, integral to the delivery of safe and efficient care. At the same time, however, despite most pager calls being judged by residents to be appropri-ate, qualitative results suggest a high level of annoyance and frustration among junior doctors when interrupted by pages. 14 Such stresses are typically associated with other consequences of interruption, like increased cognitive burden. This finding is telling because it highlights the complexities in seeking to understand when, how, and how often the potentially negative consequences of interruptions to clinical work outweigh the more evident benefits of instant communication to facilitate the delivery of appro-priate, timely care. Unfortunately, few studies to date have linked inter-ruptions to specific clinical outcomes. Our study of nurses and medication administration errors is one example. 16 We found a significant correlation between more frequent interruptions and more numerous—and more serious— errors in administering medication. As yet, there is no published comparable study, to our knowledge, linking clinical outcomes to interruption rates for physicians. Although there has been some research into measures to reduce interruptions, many questions remain unanswered about their effectiveness. Two decades after the introduc-tion of the Sterile Cockpit, several anecdotal and descrip-tive accounts of hospitals applying similar isolation-type concepts appeared. 17–23 These included applying a ''no interruption zone'' for preparing and checking medications and the use of ''no interruption vests.'' However, a lack of