28 The Effect of Crowding on the Workload and the Perception of Workload in a Community Emergency Department

Abstract

Crowding of emergency departments (EDs) adversely affects patient safety, staff turnover and patient satisfaction. Our objective was to measure the changes in workload and perception of workload during ED crowding. Design - The time on task, task type, interruptions, and the number of tasks performed by physicians (MDs) and midlevel providers (MLPs) were recorded during this observational study. Subjective workload was measured using the validated NASA-TLX score after each hour of observation. ED operational data were obtained from the EDIS system. Pearson correlation was used to analyze the results. IRB approval was obtained. Setting - The study was conducted in a community hospital with occasional resident or medical student coverage during a convenience sample of 42 hours between the hours of 8am and 1 am May 1 to August 31, 2009. This ED has a yearly volume of 32000 with 42 hours of physician and 42 hours of MLP coverage per day. During the study period, the ED used paper charting, an electronic tracking board, and electronic lab results reporting, and digital radiography with electronic results reporting. Participants- 6 MDs (6/11) and 4 MLPs (4/8) volunteered to be observed. During the 42 hours of observation, there were 901 patients triaged. The mean ED occupancy was 59%; however, this counted chairs, special procedure rooms and hallway beds which were not always in use. The mean EDWIN score was 0.82. There was a mean of 6 +/- 4.7 (range 0-18) patients in the waiting room. Mean triage severity score was 3.35 (5 most severe). There was no significant difference in the percentage of time spent on tasks or the number of interruptions during times of high occupancy. Subgroup analysis showed a decrease in the time spent on direct patient care (r=-0.42, p<0.05) and an increase in the time spent admitting patient s(r=.41, p<0.05) when the number of patients assigned to a provider increased. An increase in subjective workload correlated with occupancy (r=0.57, p<0.001) and the number of patients in the waiting room (r=0.38, p<0.03). An increase in subjective workload correlated with an increase in viewing the electronic log (r=0.37, p<0.05), less time spent communicating with staff (r=0.38, p<0.2), less time on breaks/downtime (r=-0.41, p<0.02) and greater frustration (r=0.40, p<0.02). In this study, ED crowding produced little change in the actual tasks or time spent on tasks by providers. However, it did change the perception of work and frustration. These perceptions and frustrations and the anxieties that accompany them may be 1 reason that crowding leads to adverse patient safety conditions. Further research is necessary.