The practice of emergency medicine/original research
A Task Analysis of Emergency Physician Activities in Academic and Community Settings

Presented at the American College of Emergency Physicians October 2006 Scientific Assembly, New Orleans, LA, October 2006.
https://doi.org/10.1016/j.annemergmed.2010.11.026Get rights and content

Study objective

We characterize and compare the work activities, including peak patient loads, associated with the workplace in the academic and community emergency department (ED) settings. This allows assessment of the effect of future ED system operational changes and identifies potential sources contributing to medical error.

Methods

This was an observational, time-motion study. Trained observers shadowed physicians, recording activities. Data included total interactions, distances walked, time sitting, patients concurrently treated, interruptions, break in tasks, physical contact with patients, hand washing, diagnostic tests ordered, and therapies rendered. Activities were classified as direct patient care, indirect patient care, or personal time with a priori definitions.

Results

There were 203 2-hour observation periods of 85 physicians at 2 academic EDs with 100,000 visits per year at each (N=160) and 2 community EDs with annual visits of 19,000 and 21,000 (N=43). Reported data present the median and minimum-maximum values per 2-hour period. Emergency physicians spent the majority of time on indirect care activities (academic 64 minutes, 29 to 91 minutes; community 55 min, 25 to 95 minutes), followed by direct care activities (academic 36 minutes, 6 to 79 minutes; community 41 minutes, 5 to 60 minutes). Personal time differed by location type (academic 6 minutes, 0 to 66 minutes; community 13 minutes, 0 to 69 minutes). All physicians simultaneously cared for multiple patients, with a median number of patients greater than 5 (academic 7 patients, 2 to 16 patients; community 6 patients, 2 to 12 patients).

Conclusion

Emergency physicians spend the majority of their time involved in indirect patient care activities. They are frequently interrupted and interact with a large number of individuals. They care for a wide range of patients simultaneously, with surges in multiple patient care responsibilities. Physicians working in academic settings are interrupted at twice the rate of their community counterparts.

Introduction

Since the 2000 Institute of Medicine report To Err Is Human,1 there has been tremendous interest in examining how physicians interact with their work environments, with specific attention paid to identifying system items that may contribute to the potential for medical error. There have been few attempts to examine systems interventions that may assist potential error reduction. One reason is that the physician work environment is poorly characterized, making comparisons with baseline difficult when system operational interventions are contemplated or initiated (eg, computerized physician order entry).

For more than a decade, we have conducted observational studies examining components of the emergency department (ED) workplace.2, 3, 4 This study was designed to weave several components together, to perform a task analysis of several ED workplaces. This allows a comparison with historical controls for some components (eg, introduction of computerized patient medical records, point-of-care testing, waterless hand cleansers widely dispersed throughout the ED, portable telephones). It also allows the most comprehensive description of the ED workplace, allowing us and others to measure future interventional strategies that may reduce error-producing conditions (eg, interruptions or reliance on memory for patient status tracking).

The goal of the study was to characterize and compare the activities of physicians practicing in academic and community EDs.

Section snippets

Materials and Methods

We performed an observational, time-motion study. The observations occurred from June through August 2006 at 2 academic EDs, each with more than 100,000 annual visits per year, and at 2 community EDs with annual visits of 19,000 and 21,000. At the time of the study, ED patient records were handwritten at all sites, and all sites used computerized electronic medical record and laboratory/radiology results.

Trained observers shadowed physicians (all American Board of Emergency Medicine

Results

We conducted 203 2-hour observation periods. Eighty-five physicians at the 2 academic EDs (N=160) and 2 community EDs (N=43) were observed. Table 1 presents the main results of the study by academic and community sites.

Emergency physicians spent the majority of time on indirect care activities. Physicians at the academic sites spent a median of 64 minutes per 2-hour observation on this category (range 29 to 91 minutes) compared with a median of 55 minutes for community emergency physicians

Limitations

The results of our study must be interpreted in light of several limitations and sources of potential error. First, although our study included as many different shifts as was possible, our shift sampling may not have been completely random. Second, “a major risk in any monitoring system is that its very presence might change the activity patterns of the observed events.”5 As described in the “Materials and Methods” section, we undertook several measures to minimize the influence of having an

Discussion

Our study represents the most comprehensive attempt to characterize physician activity in the ED workplace. Academic and community workplaces share many similar facets that are likely consistent in emergency medicine practice. Physicians spend the most time on indirect care activities, followed by direct care, with limited personal time. They interact with many individuals, and interruptions create breaks in task. ED providers experience profound variability in peak patient loads. Such periods

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Supervising editor: Robert L. Wears, MD, MS

Author contributions: CDC conceived of the research idea. CDC and CSW participated in the design, implementation, and analysis of data. CDC, CSW, and LW were responsible for preparation of the article. LW participated in the design of the data collection form and its implementation. LW was responsible for primary subject enrollment. BG participated in the design of the project, data entry, and review of the article. CDC takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Supported by the Clarian-Methodist Summer Student Research Program.

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Publication date: Available online January 28, 2011.

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