Distraction - sorry to interrupt, but can I just show you this ECG

Distractions 

Following a slight blogging holiday (bloggiday?) I thought it would be interesting to think about distractions - recently I helped deliver a human factors session at Walsall Manor Hospital, supporting a fantastic local Human Factors initiative that had seen a real culture change within the organisation. 

The session I led was around distraction and cognition and allowed me over the day to start to draw together the discussions into some type of working model on how to reduce distractions. 

The problem

Fundamentally, I really do think that distractions are so commonplace in healthcare they are seen as the norm - to such an extent we are blind to them 

• how many times will the consultant in ED running the trauma call be asked to look at a 12 lead ECG for another patient in majors
• listen to the melee of alarms screaming for attention in a critical care area
• the staff member waiting slightly impatiently to discuss another patient while a clinician performs a procedure
• or the crash bleep startles you into a response

These are all distractions and we could go on and on with examples. 

I think one episode that set me wondering about distractions was a simulation scenario with a junior paediatric anaesthetist - the scenario was around a child coming to theatre for an emergency operation and the anaesthetist was asked to prepare the drugs (and we really wanted them to draw them up) , we also explained to the anaesthetist that there was a student here who had never been in theatre and could he explain to the student what will happen when the child arrives. The junior starts gathering boxes of drugs as he started to explain the process the child was about to go through. 

So what was interesting, for me, was that the anaesthetist was about to perform quite a demanding critical task, with potential for error. 

Specifically, he had to:- 

• select the correct drug (find the right box/strength)
• check the drug ampoule
• calculate the dose from the weight of the child 
• dilute the drug / prepare drugs 
• repeat this for all the drugs required to induce, maintain and respond to emergencies during anaesthesia 

But rather than saying - “I tell you what I need to draw these drugs up,  I will speak to you after” or even “I need to draw up these drugs perhaps you could check them with me? “ he just went about the task as he talked to the student. 

It is also interesting that one area where we realise the risk of distractions is how we check a bag of blood - the training mantra is - if someone interrupts me then I start again rather than restarting in the wrong place and missing an essential check. Of course, there has been no cross over to other critical tasks, but it is a start. So perhaps we should say that if you interrupted then you must restart every task - the realisation is that we probably wouldn't get any tasks completed, so we need to probably do something a little more effective. 

Another area we have tried to reduce interruptions is nurses doing drug rounds - by placing them in red tabards, the general feeling is that this tends to be fairly ineffective maybe partially because the tabards are red - the very colour you look for in an emergency, so distractions continue though now start with an apology. 

Probably we need to start with raising the awareness with the whole healthcare team of how much of a risk distractions are. 

Awareness 

At a basic level, I think we need all staff (clinical, management and administrative) to be aware of the risks of interruptions and distractions. Both as the interrupter and as the interrupted i.e. what effect may this conversation have on other people, what effect will someone interrupting me have on me doing a task. 

As part of this awareness, it will be useful to think of distractions as either avoidable or unavoidable

Avoidable - inappropriate interruptions 

Unavoidable - appropriate interruptions  

It’s also important to remember that the degree something (or someone) is seen as an interruption will depend on the clinical situation both with respect to the number of tasks being performed (cognitive load) but also with the degree of the emergency (risk) and the required level of concentration.

Reducing avoidable interruptions

A common mental model is needed as to what constitutes a critical task - one of the issues of working in multidisciplinary teams is that there can be a lack of situation awareness of roles/tasks and procedures performed by professions, specialities that we work alongside.

As a starting point, it may be useful to a agree a list of common critical tasks for that clinical area (or non-clinical area) that interruptions should be avoided (if possible) and get these agreed - again raising awareness of the risk of interruptions. 

Furthermore, it needs to be recognised that interruptions are not just verbal ones i.e. having a member of staff “hovering” waiting to talk to you when you have finished is a distraction in itself

Once the list is agreed hopefully this will encourage staff to be more aware of tasks that others perform, and the impact of interruptions and thus encouraged not to interrupt unless it is appropriate 

Also, realise how noise itself can be a distraction - think about when you see a potential hazard in the distance when driving and how often the first thing you do is to turn off the car radio. Clinical emergencies can be really noisy and often the chatter may even not be relevant just adding to the background noise. This may even be as not everyone is even aware it is an emergency - so the good team working elements of declaring an emergency but also reducing conversation to those that are relevant/critical will actually reduce distractions and also improve communication. 

The aim should be to avoid them happening in the first place i.e. reduce interruptions and distractions

Manage unavoidable distractions

In healthcare there will always be unplanned events, emergencies and we need to consider how we manage these 

• effective communication - interruptions should be communicated in a way that everyone understands what is happening i.e. the emergency declared and closed-loop communication used - remember in stressful situations there is a physiological stress response that results in tunnel vision and people not hearing conversations aimed at them

• decision making - If staff are already engaged in a task they need to consider the need to stop the existing task (if that is possible) rather than rushing the task or trying to do the task and have a conversation about something else. 

• leadership - where multiple conflicting tasks exist there will be a requirement to decide an appropriate course of action and allocate resources.  This process also requires attention and necessary bandwidth i.e. we do not want to be distracted by the clinical task we are doing. Where possible it may that we can ask another member of staff monitor the patient while the senior person makes decisions. 

Systems and technology 

It is really important that our systems and technology also avoid distracting us - thinking back to the orchestra of alarms in ICU and realising that more careful alarm could have diagnostic equipment having a hearty of alarms (pre-warn, warning, alert) but also interrogate each other i.e. if the sats probe is detecting a pulse but the arterial line is unable to detect a waveform its more likely to be an issue with the A-line than the patient so could alert staff more appropriately. 

Technology should be designed to reduce distractions if the users were more engaged - think of bleeps going off when people are busy i.e. the pile of bleeps left in an operating theatre during an emergency that are being ignored but still causing a distraction - opportunities like geofencing and diversion of bleeps must be technically possible. 

Conclusion 

Distractions are so common in healthcare that we almost don’t see them anymore - there is a real need to raise the awareness of the threat of distractions and to start to reduce and manage them. Simulation can be used to develop team working but we also need to think about how our systems, equipment, technology and environment could also reduce distractions.