Emergency department crowding and provider workload

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Title: Emergency department crowding and provider workload
Author: Coles, Kathryn
Abstract: This observational field study attempted to quantify the objective task load imposed on emergency department (ED) providers, determine the degree of subjective workload they experience, and to correlate these data with ED operational metrics, mainly ED crowding metrics. Participants were a convenience sample of 10 emergency care providers; the 3 female and 7 male participants represented a variety of provider levels (6 physicians, 3 physician assistants, and 1 nurse practitioner). Forty-two hours of data were collected. ED variables were obtained from the hospital's existing information system each hour and included the Emergency Severity Index (ESI), number of people in the waiting room, patient/doctor ratio, patient/nurse ratio, number of patients assigned, number of providers on duty and crowding variables; Emergency Department Work Index (EDWIN) and occupancy level. Providers were shadowed and observed each hour by a researcher who recorded the type of tasks they performed, the number of tasks they performed, the time they spent on each task and the number of times they were interrupted. Subjective workload ratings (NASA-TLX) were obtained from providers at the end of each hour of observation. Correlations were performed to evaluate the relation of observed, subjective and hospital variables. Overall objective task load was quantified using time-on-task data and task difficulty weightings to achieve a single standardized value for overall objective workload (OTLX). OTLX scores were regressed against ED crowding measures of occupancy and EDWIN score. Structured interviews were conducted with each participant following the observation sessions. Results from the study revealed that providers spent 75 percent of their time performing tasks related to communication with staff, direct patient care, and paperwork. The other 25 percent of their time was spent checking test results, admitting patients to the hospital, taking breaks, looking for supplies, checking the electronic whiteboard, and other job-related tasks. ED occupancy was positively correlated to subjective workload and predicted 30 percent of the variance in subjective workload. The EDWIN score, on the other hand, only predicted 9 percent of the variance in subjective workload. This study revealed no correlation between ED crowding and objective task load and ED crowding predicted less than 4 percent of the variance in OTLX scores. In accordance with "Occam's razor", ED occupancy may provide an advantage over more complex compound measures of ED crowding such as the EDWIN score in predicting provider subjective workload and may be more useful in making ED staffing and scheduling decisions. In addition to collected and recorded variables, valuable insights were obtained from ED providers regarding issues of ED crowding, time-pressure and workload. It is apparent from their responses that, in the absence of observable changes in task load, the quantity and status of the "unseen" patient weighs heavily on their minds. Future research should assess the number of patients waiting or the number of patients who have left without being seen (LWBS) not only as a metric of ED crowding but as a predictor of ED provider workload.
Record URI: http://hdl.handle.net/1850/13608
Date: 2010-08-31

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