Ideally, medical care should be provided by a well-rested and nourished provider to one patient at a time through the course of their treatment, with separate time dedicated to teaching. Emergency medicine challenges this concept. The ED consists of shifts around the clock, managing multiple patients without a break but with constant interruptions, where patients are transferred between multiple providers and where learning and teaching can fall by the way side.
Whereas residency focuses on the clinical practice how to provide emergency medical care to individual patients, it doesn’t teach much about the physical practice of how to manage a department—which plays a huge role in patient care and provider stress. What follows is a framework for this broader aspect of emergency medicine shift work—both the threats to patient safety and provider stress and what we can do to minimize them. I’ve organized these tips into the mnemonic SHIFT: Sleep, Handoff, Interruptions, Food, and Teach.
SLEEP: PHYSIOLOGICALLY PREPARE
Shifts in the ED are exhausting and affect cognitive function, especially those that disturb circadian rhythm. This study found that the memory of interns in the ED deteriorates through the course of night shifts, while this study found that short-term memory declines after shifts regardless of the time of day—and that a third of physicians reported poor sleep and chronic fatigue. According to this survey, 90% of EM residents use caffeine during night shifts, and a third use sedative agents to sleep following shift work.
Getting enough sleep is not only important for our long-term health, but is critical to providing good patient care. As a helpful review reminds us, “our first task is to acknowledge the importance of fatigue reduction as a strategy to prevent medical errors…We must attend to our own bodies and minds, as individuals and as a specialty, in order to deliver the clinical excellence that our patients rightfully expect and deserve…sleep quality can be enhanced with careful planning. The most important hurdle to overcome is recognition that sleep management should be a high priority. There is no substitute for adequate time sleeping. This will inevitably conflict on occasion with work-related and family responsibilities, but the safety of patients and personal well-being deserves precedence”
It outlines a number of tips
- shift schedule
- rotate shifts clockwise
- clear your schedule before/after a nigh shift
- avoid grouping night shifts, which doesn’t help your circadian rhythm
- sleep management
- nap before evening shifts and before/after night shifts
- sleep hygiene: dark room (+/- eye cover), quiet (+/- ear plug or noise machine)
- avoid caffeine 6 hours before you need to nap/sleep
- sleep after your shift before driving home
HANDOFF: DEPARTMENT, PATIENTS, LEARNERS
Even before seeing your first patient, your shift starts with you inheriting the department in its current state, assuming responsibility for patients being handed off by physicians physiologically drained at the end of their shift, and starting a shift with staff and residents. As this review highlights, the ED has “unique operating characteristics: multiple and often overlapping patient encounters, unscheduled care, incomplete historical data, unpredictable patient presenting conditions, and variable practice settings. All of these are exacerbated during transitions.”
1) The first handoff is the department as a whole, the context that will shape your shift which you need to know before hearing about or seeing any individual patients. One mnemonic developed for assessing these areas is ABCDE:
- Areas/allocation: volume, wait times, other docs working
- Beds/bugs/breaches: beds available, isolated patients
- Colleagues/consultants: staffing, shortages, consultants
- Equipment/external events: shortages, major events
2) The second handoff is specific patients. The focus is on those you are taking responsibility for, but you should also be aware of those still in the department awaiting discharge and those awaiting admission—especially those who are sick or potentially unstable.
A survey of EM residents found at least one error in transition of care every five shifts—incomplete history, ineffective transfer of good information, good transfer of ineffective information, or poor receipt of good information—with 40% of errors having a perceived impact on care. Errors in handover can result in delayed or faulty diagnosis, treatment, and disposition. According to a study of ED malpractice claims, “handoff breakdowns were present in almost a quarter of the missed diagnoses identified. There is a growing awareness of the implications of discontinuities in care; our findings underscore the fact that the diagnostic process in the ED is also affected. Strategies being promoted nationwide to improve these discontinuity problems through standardized handoff procedures and communications should not ignore the ED.”
Inpatient pediatric handover interventions have reduced the diagnostic error rate by a quarter, and there’s increasing use of standardized handover procedures in the ED. Ten years ago, a survey of EM residency program directors found that most handoffs were verbal, not documented, not standardized and not taught. A closer analysis on the information conveyed during handover showed that they conveyed what was known and completed (past medical, presentation, tests and treatment) but not what was to be done (outstanding issues, tests and treatment)—with the results being delayed tests/treatment/disposition, and confusion around the treatment plan and follow-up. Even such simple but vital information such as hypotention or hypoxia has been found to be omitted in nearly 1 in 7 ED handoffs.
In 2010 ACEP called for standardized handoffs, including: limiting unnecessary handoffs, limiting interruptions during handover, standardizing handoffs (patient acuity, incomplete information and contingency), and encouraging questions/discussion during handover. Last year, a survey found there has been progress on handoffs: more programs are using standardized handoffs and including them in training. But there is ongoing frustration with the process, lack of documentation and lack of evaluation. Another survey developed the following algorithm: set the stage (uninterrupted time and space with access to medical records), assemble the team, identify high-risk patients (both those being formally handed over, and those boarding or awaiting admission), use a structured handoff, and close the loop (document, ask questions, and assess state of the department).
When done well, a brief checklist can increase awareness of staff and patients, and promote communication, safety and efficiency. As one academic pediatric ED found, a brief checklist helped identify a mean of 1.7 safety events per handoff—including ICU-level patients in the ED, equipment problems, staffing issues, and ICU-level patients in transport.
There are a number of handoff approaches and mnemonics, and what’s important is that the handoff be standardized, used, documented and taught, eg I-PASS:
- Illness severity
- Patient summary
- Action list
- Situation awareness and contingency plans
- Summary by receiver
3) The third handoff of situational awareness is meeting your students or residents and discussing goals/expectations for the shift.
Not taking handoff seriously can mean starting a shift unaware of missing equipment and sick patients, taking inadequate responsibility for a patient at high medico-legal risk, and working with a learner without discussing goals/expectations of teaching. On the other hand, taking handoff seriously can provide situational awareness of the department, anticipate patient safety issues, streamline transition of care and set the stage for quality education.
INTERRUPTIONS: MANAGE TASK-SWITCHING
Emergency medicine is filled with interruptions: “The emergency department (ED) workplace may be particularly susceptible to interruptions. The workload in EDs is uncontrolled and unpredictable and punctuated by intermittent time-critical activities. Patient visits are unscheduled and there are irregular peaks and troughs in the number of patients and acuity levels of illness and injury. Emergency physicians (EPs) must constantly shift their priorities to optimize care.” As this time-motion analysis found, EPs experience interruptions (requiring brief attention) once every six minutes, and breaks in task (requiring a complete change) in task once every nine minutes.
This has led to the belief that EM is based on “multi-tasking,” but this is a myth. As one review explained, “Although we manage multiple patients, we do not multitask, and in the interest of patient safety we should not strive to do so. Emergency physicians do excel at the skills of prioritization and task-switching, both learned through experience. Prioritizing between patients, illnesses, and interruptions is a defining feature of our specialty. It is the foremost skill acquired during residency and is refined through clinical practice. EPs learn patterns, develop rules, and prioritize for a range of circumstances. We use mental checklists, computer devices, and other prompts to speed recovery when distracted or switching between tasks. Emergency medicine trainees should endeavor to complete one important task at a time, learn to prioritize expertly, and use techniques that consistently aid in recovery from distraction. These are the requisite skills for mastering the clinical practice of EM rather than the elusive ability to multitask. “
In fact, glorifying multi-tasking undermines patient safety. As one study found, “Some multitasking is initially beneficial, but that excessive multitasking is detrimental to productivity…Although beneficial at lower levels, at higher levels, multitasking was also found to adversely impact patient quality of care: physicians who multitask excessively are likely to make fewer patient diagnoses, and their patients are more likely to revisit the ED within 24 hours.”
With this in mind, it’s worth separating task-switching into the positive skills can develop and the negative habits we can reduce.
1) develop task-switching skills
As this review explained, emergency medicine requires provider skills we need to develop and teach: prioritizing tasks, considering whether task-switch can be delayed, and reducing cognitive load by practicing clinical assessments and procedures, and developing mental frameworks. To reduce managing too many patients at once, there’s also the skill of planning reassessments to discharge or admit patients, to promote patient flow and reduce cognitive load.
2) reduce unnecessary interruptions
Interruptions are relative, depending on the task being interrupted and the task doing the interruption. At one end of the spectrum, if you are intubating a patient you should never be interrupted with a lab result from another patient; at the other end, if you are writing in a chart and a patient codes you should always be interrupted. Most interruptions in the ED fall between these extremes, but most are not critical and do not change task. According to one observational study, interruptions averaged less than a minute and rarely caused a change in task. There was less interruption while the EP was on the phone, and less if the EP was charting where they could not be seen—both reaffirming that many interruptions can wait. Rather than accepting all interruptions as being inevitable, we should foster a work environment that reduces unnecessary interruptions: turn off phone/pager when not needed, delegate tasks, use order sets to reduce cognitive load, educate staff on stratifying interruptions to delay those that can wait and providing interruption-free zones for critical tasks.
FOOD/DRINK: PHYSIOLOGICALLY REPLENISH
As well as reducing unnecessary interruptions, we need to remember to plan necessary interruptions to eat and drink. Like the physiological preparation of sleep before a shift, it’s important to take a break during a shift to eat and drink—both to physiologically recharge and to cognitively unload and de-stress. It’s easy for a shift to fly by without adequate nourishment, which contributes to the reduced cognitive functioning observed at the end of a shift. While you should turn off your cell phone to avoid unnecessary interruptions, you can set your alarm for halfway through your shift as a reminder to take a couple of minutes away from the demands of the department for essential food for thought.
Every shift in the ED is a goldmine for teaching, learning, quality improvement and sharing. It is an error of omission not to use every shift to prepare yourself and others for the next.
1) teach efficiently
As well as the myth of multi-tasking, there’s the myth that a busy ED makes it difficult to teach. But as one study found, “Increased clinical workload does not adversely affect clinical teaching…The clinical teaching skills, willingness to teach, and learning environment established by the attending physician (as perceived by the resident) all significantly correlated with the overall teaching scores given.” Like everything, teaching is a skill that can learned and adapted to the ED.
There are some general tips for bedside teaching in the ED: plan before your next shift, know your team and their goals, choose the right time, set expectations, limit time per patient, be professional, use Socratic method with caution, summarize, teach-only attending and train residents to teach. This starts at the department handoff where you assess the state of the department and your learners, and can respond to the volume and acuity: if it’s quiet you can take the time for a mini lecture, or if you’re busy with critical patients you can invite junior learners to delegate tasks to senior learners.
There are also specific methods for teaching in a busy emergency department
- the teachable moment: brief targeted educational pearl (history/physical for junior learners, medical decision making or patient flow for senior)
- one minute preceptor: ask for commitment, probe for evidence, find generalizable point, offer positive reinforcement and constructive criticism
- SNAPPS: learner initiative format to Summarize, Narrow, Analyze, Probe, Plan and Select future learning
- Aunt Minnie: student sees patient and presents presumptive diagnosis, preceptor sees patient and discusses
- Two-minute observation: observe history/physical, with feedback
- Activated demonstration: demonstrate skill
- See one, do one, teach one: for procedures
- Teaching scripts: mini-lectures prepared in advance
- MiPLAN: Meet to discuss goals, introduce patient, and after review Patient care, Learner’s questions, Attending’s agenda, and Next steps
- Ask-tell-ask: ask for self-evaluation, tell both positive and corrective, and ask for strategies
2) learn and improve
Due to the high-volume and high acuity of undifferentiated patients—compounded by sleep deprivation, faults in handoffs and unnecessary interruptions—it’s not surprising that diagnostic errors are common in the ED. Whether it’s voluntary reports or computer tracking of return visits, we should use each shift to identify and learn from errors, so that we can improve education and patient care.
Social media has greatly expanded the ability to learn and share with the emergency medicine community. Through #FOAMed we can all learn, share and improve—from the latest scientific studies, to creative #PostitPearls.
In summary, each shift is an opportunity to improve our cognition physiologically, stream-line our task switching, and enhance education and quality improvement. Here’s a prescription for your next SHIFT: