Feeling the pressure in ED
In last month’s blog, ED was shown as a pressure vessel with the caption ‘As pressure mounts negative factors impair performance.’
Software designed by folk who have never experienced this pressurised and distracting environment first-hand often makes matters worse.
In order to do better, one needs to understand the issues and mechanisms of worsening performance. A&E staff need to perform well on cognitive and social tasks and psychologists talk about the extent to which adverse factors consume the ‘executive resources’ available to perform well. Staff also perform sensorimotor tasks which require automatic processing. The latter involves fluid movement such as insertion of a canula. A combination of cognitive, physiological, affective and motivational processes are likely to be operating.
Executive processor capacity & stress This is the resource needed for efficient performance of many cognitive and social tasks that require coordinated information processing while inhibiting interference from distractions. A physiological stress response has a discernible adverse impact on processing, reducing the ability to control attention and to cope with information processing demands. Paradoxically, studies suggest that attempts to cope with negative impacts on processor capacity may derail attempts to compensate in ways which increase errors.
Simplifying the tasks being performed reduces or even eliminates the negative stress impact. Familiar problem solving mechanisms also help.
Self-doubt, anxiety & vigilance Studies show that active efforts to push anxious feelings out of mind and the increased vigilance toward cues to assess one’s own performance ‘Am I doing OK?’ also consume processor resources and slow decision making. Self-doubt in the triage and UCC streaming process leads to overly risk-averse behaviour: over-triage and excess streaming to ED from UCC.
Assistance with acuity setting and streaming decisions should help.
Error rates One well recognised approach to the reduction of errors is the use of check lists. However these are of little use unless one can ensure that the right check list is used (the role of the GUI in SortED). In-use testing and error heatmaps plot where users made errors have informed design development.
Situational awareness Complex and stressful situations distort the perception of the passage of time often making time seem to pass much more slowly. We’ve added a timer to remind nurses if time elapsed time while ‘Sorting’ each patient.
How SortED’s design benefited from these insights – SortED attempts to reduce the negative impacts of stress by reducing the process into series of simple, familiar, steps. The rapid nature of the process (median time 1.43 minutes) should reduce the likelihood of interruptions and distractions and error-prone methods of data capture have been avoided. Models predict that enabling a faster process will reduce the ED length of stay and hence overcrowding – a major cause of stress in ED. Assisted acuity setting or streaming (via the PlacEDTM disposition system) should increase confidence in decision making.
Gillie Francis – Jan 2018