Presentation
The Effects of Occupational Fatigue on Care Delivery Priorities in Emergency Departments
SessionPoster Session 2
DescriptionIntroduction
Occupational fatigue has been associated with impaired clinician performance, negative health outcomes, and increased patient safety risk. Emergency department (ED) clinicians have reported both physical and mental fatigue. Fatigue has been identified in clinical settings; however, how clinicians deal with fatigue and its effect on clinical performance should be further explored. Compensatory control theory suggests that fatigue leads to the prioritization of primary tasks and the sacrifice in performance of secondary tasks. The purpose of this study was to identify (1) how ED clinicians prioritize their work; (2) describe the effects of fatigue on this prioritization; and (3) evaluate the effects of fatigue on the performance of primary and secondary tasks. Prioritization of primary and secondary tasks might identify those that are most affected by fatigue that could be modified through organizational and informatics-based interventions such as clinical decision support (CDS). CDS systems could be designed and implemented to anticipate clinician fatigue and mitigate its effects.
Methods
This study is part of a larger research effort investigating ED clinicians’ fatigue. We interviewed 29 providers from a pediatric ED in the US mountain west region. This tertiary-care referral academic ED receives nearly 72,000 visits annually, serving as a Level I Regional Pediatric Trauma Center that delivers emergency care to a wide geographic area encompassing seven states. Semi-structured interviews were conducted and guided by the compensatory control theory. The interview questions in the larger study included the challenges of decision-making, the effects of fatigue on decision-making, antibiotic prescriptions, communication patterns, and care delivery. We also asked the following three questions “(1) What are your priorities in care delivery in the ED?,” “(2) Is there any ranking among these priorities?,” and “(3) How might fatigue affect your priorities and the ranking among them?” This presentation focuses on the responses to these three questions. Using a general inductive approach and thematic analysis, participants’ responses to these questions were extracted into a tabulated form and summarized in broad terms.
Results
All participants provided their priorities. In response to questions 1 and 2, 12 primary priorities were reported (# of participants):
• Patient Safety (7)
• See and treat the sickest kids (6)
• Not missing a critical diagnosis (3)
• Provide compassionate patient centered, evidence-based care to every patient (2)
• Patients get better (2)
• Safe and high-quality care to children and their families (2)
• Help patients thrive at whatever baseline condition (2)
• Make the right decision for the patient (1)
• Establishing Trust (1)
• Treating the worry (1)
• Evaluating for an emergency medical condition (1)
• Safety of staff (1)
Patient safety and treating the sickest patients were the top cited priorities. Participants reported 10 other primary priorities. All participants reported a secondary priority and 22 of the 29 participants reported a tertiary priority. Therefore, we reported 51 secondary/tertiary priorities as listed below (# of participants).
• Efficiency in keeping patients flowing (13)
• Patient/family satisfaction (5)
• Management of care and disposition (5)
• Medical care to non-acute patients (3)
• Communication with patients and family (3)
• Patient education (2)
• Quality of care (2)
• Improve patients’ health (2)
• Being a good team member (2)
• Self-care (2)
• Do no harm (1)
• Either treat or help families understand non-emergency problems (1)
• Safety (1)
• Right, equitable care (1)
• Supporting the family members regardless of SDoH (1)
Listening to the patient (1)
Compassionate care (1)
Work life balance (1)
Use of evidence (1)
PCP satisfaction (1)
Ensure Follow up (1)
Communication with staff and families (1)
The most frequently cited secondary/tertiary priority was efficiency in keeping the patients flowing. Patient/family satisfaction and management of care and disposition were next most cited secondary/ tertiary priorities. The priorities in both lists are not mutually exclusive due to the qualitative design of the study and the realities of patient care. For example, in the first list, the primary priorities “patient safety” and “not missing critical diagnosis” may overlap. There were also many priorities that were only cited once. These were due to not grouping many responses under broader categories to preserve the authenticity of the responses. Additionally, some participants reported patient safety as the primary priority while another participant reported it as a secondary priority; or a participant reported “patients get better” as the primary priority and another “improve patients’ health” as a secondary priority.
Participating ED clinicians identified priorities differently. Some participants prioritized based on the activities of the entire span of the ED process i.e., from diagnosis and management of care to discharge. On the other hand, the level of these activities (e.g., “see and treat the sickest kids” vs. “not missing a critical diagnosis”) could differ by participants. Another group prioritized care needs based on evaluation criteria or outcomes such as safety versus patient/family satisfaction. Another way of conceptualizing priorities among participants was based on the hierarchy of goals (e.g., treat the sickest patients vs. care to non-acute patients). Some focused on the specific individuals who were involved, e.g., staff safety is first followed by patient safety.
The majority of participants reported the impact of fatigue on the priorities was less on primary priorities than secondary priorities. One participant stated that “[fatigue] affects more low acuity kids.” Another stated that “I would say [fatigue] affects my lower priorities first – meaning compassion, then effective care, and safety.” Another reported: “I’ll have less motivation and energy to do those sort of lower priorities…” When fatigued, providers focused on primary high-acuity priorities, while lower priority tasks became less important to address – such as antibiotic stewardship and judicious diagnostic testing. Some participants noted a tendency to avoid deciding about patient management until another clinician could weigh in from an oncoming shift, or by admitting the patient for further evaluation. These decision delays contribute to organizational inefficiencies in patient flow through the emergency department. A few participants suggested that fatigue affects all priorities in a similar way: “I believe it effects [priorities] across the board probably to some degree”
Discussion and Conclusions
This study qualitatively explored priorities of ED clinicians in a pediatric ED and how occupational fatigue could affect these priorities. Fatigue was also viewed as an adaptive regulatory process that protected high-priority performance goals at the expense of low-level goals as suggested by compensatory control theory. However, previous research showed that fatigue may also lead to incorrect task prioritization.
This study suggests that the decision support needs of fatigued clinicians differ from those not fatigued, necessitating an adaptable CDS that promotes safe care. Specifically, secondary priorities could be noted by CDS without distracting from primary priorities or adding burdens to clinician workloads. CDS developers and implementers should ensure that clinicians’ interaction with CDS serves their changing needs and preserves safe decision-making. In an environment that promotes fatigue through rapid decision-making, rotating shift work, and prolonged cognitive workloads, CDS systems could be used as a mechanism to support clinician resilience. Enhanced clinician resilience could lead to fewer missed diagnoses, consistent application of evidence-based guidelines, and increased decision-making efficiency. Patient care outcomes would be optimized from the delivery of higher quality care through reduced effects of fatigue on ED clinicians.
Occupational fatigue has been associated with impaired clinician performance, negative health outcomes, and increased patient safety risk. Emergency department (ED) clinicians have reported both physical and mental fatigue. Fatigue has been identified in clinical settings; however, how clinicians deal with fatigue and its effect on clinical performance should be further explored. Compensatory control theory suggests that fatigue leads to the prioritization of primary tasks and the sacrifice in performance of secondary tasks. The purpose of this study was to identify (1) how ED clinicians prioritize their work; (2) describe the effects of fatigue on this prioritization; and (3) evaluate the effects of fatigue on the performance of primary and secondary tasks. Prioritization of primary and secondary tasks might identify those that are most affected by fatigue that could be modified through organizational and informatics-based interventions such as clinical decision support (CDS). CDS systems could be designed and implemented to anticipate clinician fatigue and mitigate its effects.
Methods
This study is part of a larger research effort investigating ED clinicians’ fatigue. We interviewed 29 providers from a pediatric ED in the US mountain west region. This tertiary-care referral academic ED receives nearly 72,000 visits annually, serving as a Level I Regional Pediatric Trauma Center that delivers emergency care to a wide geographic area encompassing seven states. Semi-structured interviews were conducted and guided by the compensatory control theory. The interview questions in the larger study included the challenges of decision-making, the effects of fatigue on decision-making, antibiotic prescriptions, communication patterns, and care delivery. We also asked the following three questions “(1) What are your priorities in care delivery in the ED?,” “(2) Is there any ranking among these priorities?,” and “(3) How might fatigue affect your priorities and the ranking among them?” This presentation focuses on the responses to these three questions. Using a general inductive approach and thematic analysis, participants’ responses to these questions were extracted into a tabulated form and summarized in broad terms.
Results
All participants provided their priorities. In response to questions 1 and 2, 12 primary priorities were reported (# of participants):
• Patient Safety (7)
• See and treat the sickest kids (6)
• Not missing a critical diagnosis (3)
• Provide compassionate patient centered, evidence-based care to every patient (2)
• Patients get better (2)
• Safe and high-quality care to children and their families (2)
• Help patients thrive at whatever baseline condition (2)
• Make the right decision for the patient (1)
• Establishing Trust (1)
• Treating the worry (1)
• Evaluating for an emergency medical condition (1)
• Safety of staff (1)
Patient safety and treating the sickest patients were the top cited priorities. Participants reported 10 other primary priorities. All participants reported a secondary priority and 22 of the 29 participants reported a tertiary priority. Therefore, we reported 51 secondary/tertiary priorities as listed below (# of participants).
• Efficiency in keeping patients flowing (13)
• Patient/family satisfaction (5)
• Management of care and disposition (5)
• Medical care to non-acute patients (3)
• Communication with patients and family (3)
• Patient education (2)
• Quality of care (2)
• Improve patients’ health (2)
• Being a good team member (2)
• Self-care (2)
• Do no harm (1)
• Either treat or help families understand non-emergency problems (1)
• Safety (1)
• Right, equitable care (1)
• Supporting the family members regardless of SDoH (1)
Listening to the patient (1)
Compassionate care (1)
Work life balance (1)
Use of evidence (1)
PCP satisfaction (1)
Ensure Follow up (1)
Communication with staff and families (1)
The most frequently cited secondary/tertiary priority was efficiency in keeping the patients flowing. Patient/family satisfaction and management of care and disposition were next most cited secondary/ tertiary priorities. The priorities in both lists are not mutually exclusive due to the qualitative design of the study and the realities of patient care. For example, in the first list, the primary priorities “patient safety” and “not missing critical diagnosis” may overlap. There were also many priorities that were only cited once. These were due to not grouping many responses under broader categories to preserve the authenticity of the responses. Additionally, some participants reported patient safety as the primary priority while another participant reported it as a secondary priority; or a participant reported “patients get better” as the primary priority and another “improve patients’ health” as a secondary priority.
Participating ED clinicians identified priorities differently. Some participants prioritized based on the activities of the entire span of the ED process i.e., from diagnosis and management of care to discharge. On the other hand, the level of these activities (e.g., “see and treat the sickest kids” vs. “not missing a critical diagnosis”) could differ by participants. Another group prioritized care needs based on evaluation criteria or outcomes such as safety versus patient/family satisfaction. Another way of conceptualizing priorities among participants was based on the hierarchy of goals (e.g., treat the sickest patients vs. care to non-acute patients). Some focused on the specific individuals who were involved, e.g., staff safety is first followed by patient safety.
The majority of participants reported the impact of fatigue on the priorities was less on primary priorities than secondary priorities. One participant stated that “[fatigue] affects more low acuity kids.” Another stated that “I would say [fatigue] affects my lower priorities first – meaning compassion, then effective care, and safety.” Another reported: “I’ll have less motivation and energy to do those sort of lower priorities…” When fatigued, providers focused on primary high-acuity priorities, while lower priority tasks became less important to address – such as antibiotic stewardship and judicious diagnostic testing. Some participants noted a tendency to avoid deciding about patient management until another clinician could weigh in from an oncoming shift, or by admitting the patient for further evaluation. These decision delays contribute to organizational inefficiencies in patient flow through the emergency department. A few participants suggested that fatigue affects all priorities in a similar way: “I believe it effects [priorities] across the board probably to some degree”
Discussion and Conclusions
This study qualitatively explored priorities of ED clinicians in a pediatric ED and how occupational fatigue could affect these priorities. Fatigue was also viewed as an adaptive regulatory process that protected high-priority performance goals at the expense of low-level goals as suggested by compensatory control theory. However, previous research showed that fatigue may also lead to incorrect task prioritization.
This study suggests that the decision support needs of fatigued clinicians differ from those not fatigued, necessitating an adaptable CDS that promotes safe care. Specifically, secondary priorities could be noted by CDS without distracting from primary priorities or adding burdens to clinician workloads. CDS developers and implementers should ensure that clinicians’ interaction with CDS serves their changing needs and preserves safe decision-making. In an environment that promotes fatigue through rapid decision-making, rotating shift work, and prolonged cognitive workloads, CDS systems could be used as a mechanism to support clinician resilience. Enhanced clinician resilience could lead to fewer missed diagnoses, consistent application of evidence-based guidelines, and increased decision-making efficiency. Patient care outcomes would be optimized from the delivery of higher quality care through reduced effects of fatigue on ED clinicians.
Authors
Event Type
Poster Presentation
TimeTuesday, March 244:45pm - 6:15pm EDT
LocationRhinelander Gallery
Hospital Environments