Essays March 2013

Call-Lights Are On - Are Caregivers Distracted?

Hugh MacLeod and Paula Davies-Scimeca

 

Good day, back on the balcony of reflection with a guest, Paula Davies-Scimeca a champion for nursing.  A journey to a better place must begin with an honest look at where we stand. In healthcare, it begins by acknowledging that the best care can’t possibly be offered by distracted care providers.

Our business is health. We are ostensibly the health experts.  Day in and day out the healthcare system delivers exceptional care through passionate and skilled providers. Yet, we have created two serious health issues. First, we have a staggering number of preventable patient safety incidents and system delivery errors. Second, healthcare workers are among the unhealthiest of all workers. The healthcare system has a high rate of occupational injury and absence, resulting in an extraordinary percentage of payroll lost due to long term disability, workplace injury and sick leave.

Although absenteeism is often used as the measure for lost productivity, it does not reflect the full scope of the problem. The term ‘presenteeism’ describes the losses in productivity and quality attributable to the walking wounded — be they impaired physically, cognitively or emotionally by illness, injury or workplace culture.

For our personal benefit — we are all patients — and for the long term benefit of the society, we can’t afford to lose the people sustaining this system. We urge all senior decision makers, planners, policy makers, theory experts, educators and tool kit designers to spend time on the wards. Talk to frontline staff. Be present in the moment. See and feel what their work life is really like. And, here comes the critic, the Ghost of Healthcare Despair with a blast:

“The unhealthy state of your work force is not improving.  In fact, with an aging workforce it’s likely getting worse. Any private sector firm with your employee health issues — not to mention, your safety and quality record — would be bankrupt. You treat employee and patient harm like just another cost of doing business. You are obsessed with science and technology. You deny any human cost to patients and staff. Yet you are in healthcare. You can’t claim ignorance. You know what is going on. In addition to unhealthy work environments you have new challenges to being present in the moment and that is distractions by new technology”.

Healthcare is demanding. It demands of caregivers their full attention, at all times. Thus, the financial costs of presenteeism are significant. Yet, even they pale in comparison to the mistakes and lapses in patient care caused by inattention. Unhealthy work cultures contribute to presenteeism. So do personal issues.

In addition to unhealthy work cultures and employee health concerns, advances in technology are now creating new presenteeism challenges. Sophisticated technology floods every industry with promises to improve communication, conserve time and reduce energy expenditure. Yet technology can erode staff focus and attention on the job at hand. Distractions during the workday are frequent. Staff can be reached anywhere, anytime.

Years ago, only outside emergencies would interrupt a healthcare worker’s day. Now, it’s common for them to receive texts throughout the shift with blow-by-blow descriptions of unimportant trivia from friends or family. Nowadays, distracting data infiltrates the healthcare environment more frequently than intravenous lines are inserted or withdrawn. And it seems many workers would rather amputate a digit than be stripped of their electronic connectivity. The full impact of social media and other technology on patient safety and quality of care is as yet unknown and the balance between the benefit and the cost is uncertain. However, the addition of another source of distraction to healthcare environments that are often considered “controlled chaos” raises many concerns about increasing risk of patient safety incidents.

Let’s use a couple of scenarios to make the point. It’s Monday morning and your employees are at their station, or desk working. F is thinking about his personal bankrupcy that is making it hard for him to concentrate. H is dealing with depression, so missed some deadlines. And G is busy at work trying to find home care support for a family member, and made some work errors that could cause future issues. They are all at work, but they are not really all there. One study showed a 28 percent drop in productivity when employees missed work altogether versus a 72 percent drop when they were at work but not really present. We are reminded of this famous quote…”Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous”.

Distraction not being present in the moment is like an illness. It invades every workplace, but the consequences are more problematic in healthcare. It must be assessed, diagnosed and treated on an individual basis. To elevate the complexity of the situation lets add potential health technology hazards. Recently the CRI Institute released a paper titled Top 10 Health Technology Hazards for 2013:

  1. Alarm Hazards
  2. Medication administration errors using infusion pumps
  3. Unnecessary exposures and radiation burns from diagnostic radiology procedures
  4. Patient/data mismatches in EHRs and other health IT systems
  5. Interoperability failures with medical devices and health IT systems
  6. Air embolism hazards
  7. Inattention to the needs of pediatric patients when using “adult” technologies
  8. Inadequate reprocessing of endoscopic devices and surgical instruments
  9. Caregivers distractions from smartphones and other mobile devices
  10. Surgical fires

Collectively we must look truth in the face if we are to prevent harm. Given the fast pace of healthcare coupled with the potential hazards associated with technology we must be forever vigilant and not get trapped in complacency and indifference. What’s even more challenging is new technology makes it easier for providers to create their own interruptions. To illustrate this point, a case study summary from the above referenced ECRI Institute paper:. A resident physician (at an unnamed facility) was using a smart phone to enter an order in the facility’s CPOE system. The order, as requested by the attending physician, was to stop anti-coagulation therapy for a patient. Before completing the order, however the resident received a personal text message. The resident responded to the message by text, but never went back to the complete order in the CPOE system. As a result, anticoagulation therapy continued unnoticed for several days, and the patient developed conditions that necessitated emergency open-heart surgery.”

To make the point, a 2010 survey of 439 perfusionists, found that more than 55 percent reported using their cell phones during procedures. Nearly 50 percent admitting texting, and 21 percent checked their email. This quote from Dr. John Halamka Chief Information Officer of Beth Israel Medical Center says it all…”I think all of us who use mobile device have what I will call continuous partial attention. We’re engaged in our work but at the same time we are checking that e-mail or we’re glancing at that instant message. The distractions might be minor for people who work in a cubicle or a storefront, but for doctors, it can be a matter of life or death. Distracting technology isn’t new for physicians, a pager, cellphone or computer can also divert a doctor’s attention. But at least “a hospital laptop separated the doctors personal and professional lives. With the bring your own device trend, you see the blurring of that separation.”

Leaders must pay attention to the workplace environment, which includes paying attention to presenteeism and with it, distraction. We suggest asking these questions:

  1. Potential For Harm – How dangerous is presenteeism and distraction? Can it kill someone or cause serious harm?
  2. Frequency – Does presenteeism and distraction happen often? How do you Know?
  3. Reach – How widespread is presenteeism and distraction? Does it affect many people?
  4. Indifference – Is the problem to large to tackle? Could the problem lead to a cascade of downstream incidents?
  5. Profile – Is presenteeism and distraction a high profile agenda item?

 

Next Week’s Guest on the Balcony of Personal Reflection: W. Nicklin in a conversation titled “Empathy Foundation For New Conversations”. 
 

Click here to see the First Series of Ghost Busting essays.

Click here to see essays from the Second Series: The Ghost of Healthcare Consciousness. 

About the Author

Hugh MacLeod is CEO Canadian Patient Safety Institute. Paula Davies-Scimeca a professional nurse, author and educator devoted to examining and writing about chemical dependency in nursing.

References

Controlling Presenteeism”.  http://www.kaiserinsuranceonline.com
 
A Sterile Cockpit For Healthcare”.  http://oregonpatientsafety.org/
 
ECRI Institute Paper Top 10 Health Technology Hazards for 2013 Vol 41, Issue 11
 
Kaiser Health News March 26, 2012 Doctors’ Smartphones and iPads Maybe Distracting
 

Chantler C. the Role and Education of Doctors in the Delivery of Care. Lancet 1999. Apr 3:353 (9159) 

 


Comments

Charles Low wrote:

Posted 2013/07/04 at 11:07 AM EDT

How very disappointing not to find much to argue with!

A major factor for our deficiencies in these arenas remains, I suggest, "culture". We're trying to trim old sails on a square-rigger, when we need new sails on a modern schooner. It's time for a revamp. Changing culture is huge, a generational topic in some ways, but I don't think that newer "procedures" or "protocols" will stick without it.

Among the strengths (and there are many) and weaknesses of our current healthcare culture, we resist learning from other industries. "Airlines" are often touted, and contacts in other occupations - nuclear energy, for example - are aghast when they hear how we operate. It's amazing that we do as well as we do (which, again, is in many ways excellently).

Who wishes to take on a generational project? Who wants to build a new ship and learn how to sail her? Who wants to be a modern Admiral (strong yet nuanced) who will hire and train a cadre of similar Captains? Much as the Western world continued sailing with square-riggers long after other societies had invented more capable designs, most of the knowledge about what we need to do is already out there, so that could make a transition a bit easier.

Banning mobile devices, for example, would be relatively easy - and yet I fear distinctly suboptimal, without addressing making safety part of our identity, instead of a collection of activities.

 

Robert Pental wrote:

Posted 2013/12/04 at 10:40 AM EST

A few items here.

First, that culture change Mr Low believes can be molded - well, I hate to be the one to break the news, but it is already begun and it is molding us. In other words, we as providers are not about to cast its shape or design. The world of constant updates and information is the new sail.
Second, health care leaders need to get on board the new ship and stop citing examples of how others need to be and become the example to be set. No longer are they going to be able to hide in the vestibule of academic parlance. And by that I mean nice essay formats with the opposing view point brought out and cuddly concluding remarks to wrap things all up. To be blunt, your scripted and edited "leadership" is not in the moment any longer because we are all in real time events. Emperor, you have no clothes.
What is more, this is not to suggest we cannot learn from other occupations. Unlike an airline industry offering sweet drinks and a discounted flights, these are not options for public healthcare providers when something goes wrong. Moreover, I don't have the authority to kick someone off the plane if they do not wish to comply with the rules/evidence and regulations/outcomes. However, if there is an en masse service industry which manages varieties of people and culture, social situations from diets to cash flow, directs outcomes from overwhelming success to incomprehensible loss, and mandates flexibility in a state of constant risk, it is Las Vegas. Does this mean putting banks of camera and removing all the clocks? No. What it means is that as a people focused service industry, it has developed a method of dealing with, and coming to terms with, the nuances of being human. It does not, in other words, remove us from our subjective or objective faults, but accepts them as a non-negotiable expandable aspect of being human. Healthcare looks for finality, strict resolution, and absolutism, while Vegas seeks to adventure on another day and in another way. Moreover, and because I can't resist this, most would prefer, "What goes into the chart stays in the chart."
Thirdly, the resident who erred on the side of being human was likely part of a team. Does this absolve the person of his or her own responsibility? No. Nonetheless, negative attitudes directed towards the use of items held of personal worth to an individual's well-being will not succeed in having them use mobile devices appropriately or in a socially acceptable manner but one of subversion. You see what the team needs to understand, no matter the individual style of ship suggested that we use, it is the oceans we must contend with, and the oceans we are now on, as never before, are open to all sailing vessels.

 

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