Analysis of Smartphone Interruptions on Academic General Internal Medicine WardsFrequent Interruptions may cause a ‘Crisis Mode’ Work Climate FundingAlon Vaisman is supported by the University of Toronto Eliot Phillipson Clinician Scientist Training Program
01 August 2016
Accepted: 07 January 2016
20 December 2017 (online)
Introduction: Hospital-based medical services are increasingly utilizing team-based pagers and smartphones to streamline communications. However, an unintended consequence may be higher volumes of interruptions potentially leading to medical error. There is likely a level at which interruptions are excessive and cause a ‘crisis mode’ climate.
Methods: We retrospectively collected phone, text messaging, and email interruptions directed to hospital-assigned smartphones on eight General Internal Medicine (GIM) teams at two tertiary care centres in Toronto, Ontario from April 2013 to September 2014. We also calculated the number of times these interruptions exceeded a pre-specified threshold per hour, termed ‘crisis mode’, defined as at least five interruptions in 30 minutes. We analyzed the correlation between interruptions and date, site, and patient volumes.
Results: A total of 187,049 interruptions were collected over an 18-month period. Daily weekday interruptions rose sharply in the morning, peaking between 11 AM to 12 PM and measuring 4.8 and 3.7 mean interruptions/hour at each site, respectively. Mean daily interruptions per team totaled 46.2 ± 3.6 at Site 1 and 39.2 ± 4.2 at Site 2. The ‘crisis mode’ threshold was exceeded, on average, 2.3 times/day per GIM team during weekdays. In a multivariable linear regression analysis, site ([uni03B2]6.43 CI95% 5.44 –7.42, p<0.001), day of the week (with Friday having the most interruptions) ([uni03B2]0.481 CI95% 0.236 –0.730, p<0.05) and patient census ([uni03B2]1.55 CI95% 1.42 –1.67, p<0.05) were all predictive of daily interruption volume although there was a significant interaction effect between site and patient census ([uni03B2]-0.941 CI95% -1.18 –-0.703, p<0.05).
Conclusion: Interruptions were related to site-specific features, including volume, suggesting that future interventions should target the culture of individual hospitals. Excessive interruptions may have implications for patient safety especially when exceeding a maximal threshold over short periods of time.
- 1 Shieh L, Chi J, Kulik C, Momeni A, Shelton A, DePorte C, Hopkins J. Assigning a team-based pager for on-call physicians reduces paging errors in a large academic hospital. Jt Comm J Qual Patient Saf Jt Comm Resour 2014; 40 (Suppl. 02) 77-82.
- 2 Wu RC, Lo V, Morra D, Wong BM, Sargeant R, Locke K, Cavalcanti R, Quan SD, Rossos P, Tran K, Cheung M. The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals. J Am Med Inform Assoc JAMIA 2013; 20 (Suppl. 04) 766-777.
- 3 Wong BM, Cheung CM, Dharamshi H, Dyal S, Kiss A, Morra D, Quan S, Sivjee K, Etchells EE. Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician. BMJ Qual Saf 2012; 21 (Suppl. 10) 855-862.
- 4 Mosa ASM, Yoo I, Sheets L. A systematic review of healthcare applications for smartphones. BMC Med Inform Decis Mak 2012; 12: 67.
- 5 Katz-Sidlow RJ, Ludwig A, Miller S, Sidlow R. Smartphone use during inpatient attending rounds: prevalence, patterns and potential for distraction. J Hosp Med 2012; 7 (Suppl. 08) 595-599.
- 6 Przybylo JA, Wang A, Loftus P, Evans KH, Chu I, Shieh L. Smarter hospital communication: secure smart-phone text messaging improves provider satisfaction and perception of efficacy, workflow. J Hosp Med 2014; 9 (Suppl. 09) 573-578.
- 7 Wu RC, Morra D, Quan S, Lai S, Zanjani S, Abrams H, Rossos PG. The use of smartphones for clinical communication on internal medicine wards. J Hosp Med 2010; 5 (Suppl. 09) 553-559.
- 8 Harvey R, Jarrett PG, Peltekian KM. Patterns of paging medical interns during night calls at two teaching hospitals. CMAJ Can Med Assoc J J Assoc Medicale Can 1994; 151 (Suppl. 03) 307-311.
- 9 Flynn EA, Barker KN, Gibson JT, Pearson RE, Berger BA, Smith LA. Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy. Am J Health-Syst Pharm AJHP Off J Am Soc Health-Syst Pharm 1999; 56 (Suppl. 13) 1319-1325.
- 10 Drews FA. The frequency and impact of task interruptions in the ICU. Proc Hum Factors Ergon Soc Annu Meet 2007; 51 (Suppl. 11) 683-686.
- 11 Potter P, Wolf L, Boxerman S, Grayson D, Sledge J, Dunagan C, Evanoff B. Understanding the cognitive work of nursing in the acute care environment. J Nurs Adm 2005; 35 7–8 327-335.
- 12 Parker J, Coiera E. Improving clinical communication: a view from psychology. J Am Med Inform Assoc JAMIA 2000; 7 (Suppl. 05) 453-461.
- 13 Weigl M, Müller A, Vincent C, Angerer P, Sevdalis N. The association of workflow interruptions and hospital doctors’ workload: a prospective observational study. BMJ Qual Saf 2012; 21 (Suppl. 05) 399-407.
- 14 Devlin MK, Kozij NK, Kiss A, Richardson L, Wong BM. Morning handover of on-call issues: opportunities for improvement. JAMA Intern Med 2014; 174 (Suppl. 09) 1479-1485.
- 15 DeVita MA, Smith GB, Adam SK, Adams-Pizarro I, Buist M, Bellomo R, Bonello R, Cerchiari E, Farlow B, Goldsmith D, Haskell H, Hillman K, Howell M, Hravnak M, Hunt EA, Hvarfner A, Kellett J, Lighthall GK, Lippert A, Lippert FK, Mahroof R, Myers JS, Rosen M, Reynolds S, Rotondi A, Rubulotta F, Winters B. “Identifying the hospitalised patient in crisis”--a consensus conference on the afferent limb of rapid response systems. Resuscitation 2010; 81 (Suppl. 04) 375-382.
- 16 Li SYW, Magrabi F, Coiera E. A systematic review of the psychological literature on interruption and its patient safety implications. J Am Med Inform Assoc JAMIA 2012; 19 (Suppl. 01) 6-12.
- 17 Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med 2010; 170 (Suppl. 08) 683-690.
- 18 Patterson ME, Bogart MS, Starr KR. Associations between perceived crisis mode work climate and poor information exchange within hospitals. J Hosp Med 2015; 10 (Suppl. 03) 152-159.
- 19 Rivera-Rodriguez AJ, Karsh B-T. Interruptions and distractions in healthcare: review and reappraisal. Qual Saf Health Care 2010; 19 (Suppl. 04) 304-312.
- 20 Coiera E, Tombs V. Communication behaviours in a hospital setting: an observational study. BMJ 1998; 316 7132 673-676.
- 21 Shayne P, Heilpern K, Ander D, Palmer-Smith V. The Emory University Department of Emergency Medicine Education Committee.. Protected Clinical Teaching Time and a Bedside Clinical Evaluation Instrument in an Emergency Medicine Training Program. Acad Emerg Med 2002; 9 (Suppl. 11) 1342-1349.
- 22 Baethge A, Rigotti T, Roe RA. Just more of the same, or different? An integrative theoretical framework for the study of cumulative interruptions at work. Eur J Work Organ Psychol 2015; 24 (Suppl. 02) 308-323.
- 23 Quan SD, Wu RC, Rossos PG, Arany T, Groe S, Morra D, Wong BM, Cavalcanti R, Coke W, Lau FY. It’s not about pager replacement: an in-depth look at the interprofessional nature of communication in healthcare. J Hosp Med 2013; 8 (Suppl. 03) 137-143.
- 24 Katz MH, Schroeder SA. The sounds of the hospital. Paging patterns in three teaching hospitals. N Engl J Med 1988; 319 (Suppl. 24) 1585-1589.
- 25 Patel SP, Lee JS, Ranney DN, Al-Holou SN, Frost CM, Harris ME, Lewin SA, Liu E, Madenci A, Majkrzak AA, Nelson J, Peterson SF, Serecky KA, Wilkinson DA, Wojcik BM, Englesbe MJ, Lynch RJ. Resident workload, pager communications, and quality of care. World J Surg 2010; 34 (Suppl. 11) 2524-2529.
- 26 Fargen KM, O’Connor T, Raymond S, Sporrer JM, Friedman WA. An observational study of hospital paging practices and workflow interruption among on-call junior neurological surgery residents. J Grad Med Educ 2012; 4 (Suppl. 04) 467-471.
- 27 Antoniadis S, Passauer-Baierl S, Baschnegger H, Weigl M. Identification and interference of intraoperative distractions and interruptions in operating rooms. J Surg Res 2014; 188 (Suppl. 01) 21-29.
- 28 O’Connor C, Friedrich JO, Scales DC, Adhikari NKJ. The use of wireless e-mail to improve healthcare team communication. J Am Med Inform Assoc JAMIA 2009; 16 (Suppl. 05) 705-713.
- 29 Wu R, Rossos P, Quan S, Reeves S, Lo V, Wong B, Cheung M, Morra D. An evaluation of the use of smart-phones to communicate between clinicians: a mixed-methods study. J Med Internet Res 2011; 13 (Suppl. 03) e59.
- 30 Sevdalis N, Undre S, McDermott J, Giddie J, Diner L, Smith G. Impact of intraoperative distractions on patient safety: a prospective descriptive study using validated instruments. World J Surg 2014; 38 (Suppl. 04) 751-758.
- 31 Westbrook JI, Coiera E, Dunsmuir WTM, Brown BM, Kelk N, Paoloni R, Tran C. The impact of interruptions on clinical task completion. Qual Saf Health Care 2010; 19 (Suppl. 04) 284-289.
- 32 Balint BJ, Steenburg SD, Lin H, Shen C, Steele JL, Gunderman RB. Do Telephone Call Interruptions Have an Impact on Radiology Resident Diagnostic Accuracy?. Acad Radiol 2014; 21 (Suppl. 12) 1623-1628.
- 33 Blum NJ, Lieu TA. Interrupted care. The effects of paging on pediatric resident activities. Am J Dis Child 1960 1992; 146 (Suppl. 07) 806-808.
- 34 Wu RC, Tzanetos K, Morra D, Quan S, Lo V, Wong BM. Educational impact of using smartphones for clinical communication on general medicine: more global, less local. J Hosp Med 2013; 8 (Suppl. 07) 365-372.
- 35 Klemets J, Evjemo TE. Technology-mediated awareness: Facilitating the handling of (un)wanted interruptions in a hospital setting. Int J Med Inf 2014; 83 (Suppl. 09) 670-682.
- 36 Smith CNC, Quan SD, Morra D, Rossos PG, Khatibi H, Lo V, Wong H, Wu RC. Understanding interprofessional communication: a content analysis of email communications between doctors and nurses. Appl Clin Inform 2012; 3 (Suppl. 01) 38-51.
- 37 Coiera E. The science of interruption. BMJ Qual Saf 2012; 21 (Suppl. 05) 357-360.