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CLINICAL

CAUSES

AND

OCCURRENCES OF INTERRUPTIONS
DURING ED TRIAGE

Authors: Kimberly D. Johnson, PhD, RN, CEN, Michele Motavalli, MBA, BSN, RN, CCRN, CEN,
Dean Gray, MBA, and Connie Kuehn, RN, Cincinatti and Cleveland, OH

Earn Up to 9.0 CE Hours. See page 520.


Introduction: Interruptions have been shown to cause errors
and delays in the treatment of emergency patients and pose a
real threat during the triage process. Missteps during the triage
assessment can send a patient down the wrong treatment path
and lead to delays. The purpose of this project was to identify
the types and frequency of interruptions during the ED triage
interview process.
Methods: A focus group of emergency nurses was organized

to identify the types of interruptions that commonly occur


during the triage interview. These interruptions would be
validated through observations in triage. A tally sheet was
developed and implemented to determine how often each
interruption occurred during an 8-hour shift. Triage nurses
completed the tally sheets while working the rst shift (7 AM to
3 PM). This shift was selected because patient intake in the US
Department of Veterans Affairs Emergency Department is
highest during this time.
Results: The categories of interruptions identied included

provision of conveniences to visitors, coworker-related interruptions, patient carerelated interruptions, locating of family
members in the emergency department, and other miscellaneous

Kimberly D. Johnson, Member, Eastern Ohio Chapter, is Assistant Professor,


College of Nursing, University of Cincinnati, Cincinatti, OH.
Michele Motavalli, Member, Cleveland Chapter, is Nurse Manager, Emergency
Department, Louis Stokes Cleveland VA Medical Center, Cleveland, OH.
Dean Gray is Process Improvement Consultant, Clear Insights LLC,
Cleveland, OH.
Connie Kuehn is Staff Nurse, Emergency Department, Louis Stokes
Cleveland VA Medical Center, Cleveland, OH.
For correspondence, write: Kimberly D. Johnson, PhD, RN, CEN, College of
Nursing, University of Cincinnati, 3110 Vine St, PO Box 210038,
Cincinnati, OH 45219; E-mail: kimberly.dawn.johnson@gmail.com.
J Emerg Nurs 2014;40:434-9.
Available online 22 November 2013
0099-1767
Copyright 2014 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2013.06.019

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JOURNAL OF EMERGENCY NURSING

interruptions. Tally sheets were completed by the triage nurses


during 10 shifts. On average, triage nurses were interrupted 48.2
times during an 8-hour shift (7 interruptions per hour). After
reviewing the data, we found that only 22% of interruptions were
related to patient care. More frequently, the causes of
interruptions were not related to patient care: opening the door
(33%), providing conveniences to visitors (21%), waiting patients
or family members asking How much longer? (14%), and other
causes (10%).
Discussion: Frequent interruptions can interfere with concentration and may affect patient care. Nonpatient carerelated
interruptions not only can be frustrating to the triage nurse but
also can be offensive to triage patients; they ultimately delay care
and may even affect the quality of care. However, because scarce
research is available regarding interruptions during ED triage, the
effects on patient outcomes are unclear. Additional research
needs to be conducted to explore the causes and effects of
interruptions to the triage process.
Key words: Emergency department; Emergency nursing;
Interruptions; Triage

patients entry into the health care system often


begins in the ED triage. The triage interview
process is the critical beginning of the treatment
experience for patients entering any emergency department. An emergency triage nurses rst assessment of a
patient is a critical step in an episode of care and can be a
good indicator of how an interaction will progress. An
incorrect triage decision, missed symptom, incomplete
assessment, or unasked question could potentially delay
care, resulting in signicant morbidity or death.
Patients who seek treatment for an injury or acute
illness may have their initial triage interview interrupted for
myriad reasons (eg, other patients needs, visitors needs, or
staff needs). Interruptions in the triage process cause
distractions that can create delays in moving patients into
a treatment area, distract nurses from collecting appropriate
triage data, or cause the nurse to make a poor triage
decision. 1 Errors during triage may adversely affect patient

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outcomes and decrease quality of care. In addition, they can


cause patients to feel devalued and vulnerable, with their
private health issues exposed to the interrupter. Furthermore, interruptions have been shown to adversely affect
nurses job satisfaction and may lead to burnout for
experienced emergency nurses. 2 The nature of the
emergency department, where the unexpected is always a
possibility, makes interruptions more likely to occur.
Until recently, there was a lack of information about
the causes and effects of interruptions in the emergency
department. The public became more aware of issues that
ED practitioners face each day after the release of the 2006
Institute of Medicine report, Hospital-Based Emergency
Care: At the Breaking Point. 3 This report discussed the
problems of interruptions and distractions and the battle to
provide high-quality care to ED patients. One potential
obstacle in providing high-quality patient care may be that
interruptions are intrinsic to the ED environment.
Interruptions have been shown to occur more often in
emergency care than in other settings. 4 In addition,
interruptions of ED providers have been linked to errors
and delays in patient care. 5 However, most studies focus on
emergency physicians, not emergency nurses. 68
Interruptions have also been studied in nursing but
focus mainly on inpatient care units. Similar to studies on
interruptions of emergency physicians, interruptions of
oor nurses administering medications have also been
linked to medical errors. 9,10 A study by Kalisch and
Aebersold 10 reported that 1,354 interruptions occurred in
136 hours, with 200 errors noted during this time.
However, little research has been conducted on how
emergency nurses are affected by interruptions because only
a few studies have focused on emergency nursing. Brixey et
al 6 studied interruptions in workow for both physicians
and nurses at a level 1 trauma center and reported that
16.45% of tasks performed by emergency nurses were
interrupted. However, only 1 study could be located that
included an assessment of interruptions in triage. 11
Although the triage nurse is part of the emergency
department, the triage nurses role is very different from
the rest of the department. During the 5- to 10-minute
triage time, the RN is expected to gather all the information
necessary to make an accurate decision regarding the need
for and timing of medical intervention. One study found
that 13% of triage interviews were interrupted. 11 However,
a study by Geraci and Geraci 12 reported that non-primary
triage functions interrupted the triage process of over half of
all patients (54%) and was linked to signicantly longer
wait times for patients with higher acuity.
This project was initiated because the emergency nurses
at the Louis Stokes Cleveland US Department of Veterans

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Affairs (VA) Medical Center believed that the triage process


was too lengthy. Their perception was that unnecessary
interruptions created delays in the triage process. Because the
triage nurses were frequently overwhelmed by the numbers of
patients needing triage, as well as other requests for service and
assistance, a second RN was added to triage during peak
hours. Despite this intervention, the nurses voiced concerns
about frequent interruptions, compromised patient safety and
privacy, and increased stress levels for the nurses. The nurses
believed that decreasing the number of interruptions would
allow them to triage patients both more accurately and more
efciently. Therefore the aims of this project were to identify
frequent causes of interruptions to the triage nurse and to
determine how often triage interruptions occur.
Methods

This work was performed as a quality-improvement project


and was part of a larger initiative to improve the ED
processes at the medical center.
SETTING

The setting is a single VA hospital emergency department


with 12 acute care rooms and 6 fast-track rooms for nonacute patients. The emergency department serves approximately 25,000 adult veteran patients annually; it does not
serve pediatric patients. The majority of patients are
assigned an Emergency Severity Index score of 3, and
patient diagnoses vary, including congestive heart failure,
acute myocardial infarction, hypertension, stroke, diabetic
complications, rashes, and pain issues. Triage is conducted
by experienced and triage-trained registered nurses. There
are 2 dedicated triage ofces, the second generally being
opened only in cases of excessive patient check-in numbers.
The triage nurse routinely performs a nurse rst
interview when the patient rst arrives, followed by a
more complete triage soon thereafter. The triage area is
secured, so the triage nurse is responsible for opening the
door for a visitor or non-ED staff. The entrance to the
emergency department and triage ofce/registration in this
setting is a busy entrance and is a thoroughfare to the main
hospital. The ED waiting room is located across from
triage, with the main thoroughfare passing through it. The
triage nurse can view the waiting room through a window
in the triage room.
DATA COLLECTION

After several iterations, not described in this article, a


process map was created by the group and approved by the
department leadership. The team discussed what activities

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TABLE 1

Number of occurrences, daily means, and standard deviations for all categories and subcategories of interruptions
Category

Subcategory

Total

Mean

SD

Opening door

For staff
For family
Other
Total for category
Asking persons to stand
backprivacy
Phone
Directions
Appointment information
Changing television channel
Requesting forms
Calling cab
Weight/blood pressure checks
Food/water
Other
Total for category
Perform electrocardiograms
Registration folders to rack
Take patient back to
emergency department
Other
Total for category
Veteran drivers asking for
disposition of veteran
Locate family member
Direct admissions issues
Coworker (nonpatient
carerelated interruption)
Total for category

77
69
12
158
22

7.7
6.9
1.2
15.8
2.2

5.2079
1.969207
1.813529
6.65332
3.155243

5
20
17
1
2
0
13
24
29
133
21
10
23

0.5
2
1.7
0.1
0.2
0
1.3
2.4
2.9
13.3
2.1
1
2.3

0.971825
1.333333
2.057507
0.316228
0.421637
0
1.567021
1.837873
2.601282
5.711587
3.107339
2.211083
4.347413

23
77
6

2.3
7.7
0.6

1.888562
7.06242
1.074968

22
4
17

2.2
0.4
1.7

2.529822
0.699206
3.267687

49
71

4.9
7.1

5.520211
8.089087

Provision of
conveniences to visitors

Patient care related

Other

Patients asking
How much longer?
Total for all categories

should be listed as an interruption. It was determined that


any activity that required the triage nurse to turn his or her
attention away from the patient being triaged or any activity
that required the nurse to leave the triage area would be
classied as an interruption. The team then developed a
tally sheet to capture each occurrence of interruption and
also document the cause of each interruption during the
triage process. Because no previous list of interruptions
specic to triage could be located within the literature, our
list was compared with interruptions reported previously in
ED settings. 6 No additional potential interruption types
were identied based on the available literature. The tally

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488

sheet was reviewed by the team, and consensus was reached


on potential interruptions to include on the data collection
sheet (Table 1). The triage nurses then used the tally sheets
to record when interruptions occurred by placing hash
marks next to specic interruptions. The documented
interruptions reected any and all triage interruptions
caused by ED staff, patients, visitors, or non-ED VA
employees. Data were gathered only during day shifts (7 AM
to 3 PM) for the convenience of the staff RN data collectors
and because the major volume of patients are triaged during
this time frame. Nurses tracked interruptions on 10 selected
days during March and June 2012. It was believed that 10

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120
100
80
60
40
20
0
Mon

Tues

Wed

Thurs

Tues

Wed

Thurs

Fri

Mon

Tue

FIGURE 1
Total interruptions per shift.

days would be adequate to determine the broad categories of


interruptions and how often they were occurring. After all
data were collected, the group reconvened to discuss
whether the tally sheets adequately captured the interruptions that had occurred or whether changes were required.

Results

The tally sheets were completed by 3 triage nurses during 10


shifts. Data collected showed a total of 488 interruptions in
the test period. On average, the triage nurses interacted with
80 patients each day. A mean of 49.8 interruptions occurred
per 8-hour shift. The number of interruptions per shift ranged
from 20 to 110, with a median of 48. A mean of 6.97
interruptions occurred per hour during an 8-hour shift.
Figure 1 depicts the total number of interruptions per day.
Table 1 shows the total number of occurrences, means,
and standard deviations for all categories and subcategories
of interruptions. On average, the triage nurses were
interrupted 15.8 times per shift to open the door to the
emergency department, whereas providing conveniences to
visitors (eg, directions, phone access, and changing the
television station) averaged 13.2 interruptions per shift.
Patient carerelated interruptions that required the triage
nurse to physically leave the triage area occurred 8.1 times
per shift. Triage nurses were interrupted by patients
inquiring how much longer they had to wait to be seen in
the emergency department 7.1 times per shift.
As shown in Figure 2, granting access to family
members and non-ED staff accounted for 32.4% of the
total interruptions and was the most signicant source of
interruptions, occurring 158 times. For the second most

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common interruption, providing conveniences to visitors,


there were 133 occurrences (27.3%). This category
consisted of interactions such as offering directions and
appointment information to non-ED patients and visitors,
asking patients to stand back while others were discussing
condential matters, and waiting room management,
which involved issues such as changing the television
channel. Patient carerelated interruptions, the third most
common interruption, occurred 81 times (16.6%), consisting of tasks requiring the triage nurses to leave the triage area
(eg, move patients into ED rooms or perform electrocardiograms in a separate room). These tasks are often
performed by other staff members, but sometimes the
triage nurse is required to perform these duties. Questions
such as How much longer? ranked fourth among
interruption categories and occurred 71 times (14.5%).
The nal general category of interruptions was other. This
category included issues with direct admission patients,
location of family members, nonpatient carerelated
coworker interruptions, and hired drivers who were looking
for the passengers they were to transport. Interruptions in
this category occurred 49 times (10%). The nurses were
accurate in their predictions about what were the most
common causes of interruptions for triage nurses. After data
collection and debrieng, no additional categories were
added to the list of interruptions.

Discussion

Interruptions are common among nurses, and the fast-paced


environment of the emergency department makes providers
even more susceptible to frequent interruptions. The

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Nunber of Interruptions

180
160
140
120
100
80
60
40
20
0
Opening Door

Convenience to
visitor

Patient care
related

Asking "How
much longer"

other

Categories

FIGURE 2
Cause of triage interruptions.

nursing staff identied interruptions as a source of stress and


dissatisfaction for the triage nurses in the department.
Because there is scarce research on interruptions in
triage, the team was required to determine whether the
denition of an interruption used in other ED studies is the
same as the denition of an interruption used in triage
settings. Our denition of an interruption was very broad:
any activity that required the triage nurse to turn his or her
attention away from the patient being triaged or any activity
that required the nurse to leave the triage area. Because
some equipment (eg, electrocardiography machine) is
located outside of the triage area, activities that are generally
considered part of the triage nurses role were considered
interruptions. We thought that it was necessary to include
these interruptions because they impacted ow.
As with any emergency department, there was some
variability in the number of patients arriving on different days
of the week. For the days during which data were collected at
our facility, the number of patients triaged ranged from 64 to
97. However, there was no signicant relationship between
the number of patients and the number of interruptions. The
lack of relationship may be because of the small number of
days sampled. Additional research needs to be conducted to
determine whether a relationship is present.
There were signicantly more interruptions on day 3, a
Wednesday, than on the other days. There are several
reasons why there was a signicant increase in interruptions
for this day. The rst possibility is that the patient wait
times were longer on this day than any of the other days, so
there were more interruptions (n = 27) of patients asking
How much longer? In addition, it was noted on the data

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JOURNAL OF EMERGENCY NURSING

collection sheet that the resident physician responsible for


treating fast-track patients was responsible for multiple
interruptions. Finally, the lack of an ED waiting room
greeter/volunteer may have contributed to the higher
number of interruptions.
In reviewing the data, we found that on the 2 days that
had more than 60 interruptions during a shift, there were no
ED waiting room volunteer/greeters present. On the days
when there were no patient carerelated interruptions or
patients asking How much longer?, there were an ED
waiting room volunteer/greeter present for the shift. Although
volunteers/greeters may be viewed as barriers, because they
may ask questions of the triage nurse, they may also assist in
improving patient ow into the department and eliminate
distractions and unnecessary interruptions for the triage nurse.
Our results show that the triage nurse is often
interrupted during private patient interviews. The impact
of these interruptions is unknown as of yet. Through
experience, it is suspected that patients may feel devalued
when their triage interview is interrupted frequently. It is
not known how frequent interruptions affect the triage
nurses concentration, ability to return to the task that he or
she was performing, accuracy of acuity assignment, or
ability to conduct a thorough assessment.
Although the occurrence of interruptions in this study is
less than that reported by Clifford-Brown et al, 11 it is
important to recognize that interruptions occur frequently in
triage. However, the critical thinking involved in triaging
patients could be compared with that required of pilots or
emergency physicians, about whom studies exist, and such
studies have shown the adverse effect of interruptions on

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concentration, returning to a task, and avoiding errors. 3,57,9,13


Although the impact of interruptions on cognition and
memory is well documented among pilots, ofce workers,
physicians, and nurses, 13 the link among interruptions,
accuracy, and critical thinking has not been explored in the
triage environment.
Limitations

The main limitation of this study was that the triage nurses
were responsible for recording when interruptions occurred.
Therefore it is possible that some interruptions were missed,
and the act of documenting the interruption may very well
have constituted an interruption.
Other limitations are the small number of days when
data were collected and the collection of data at a single
institution during a single shift. Although our data showed
common and consistent categories of interruptions, we do
not know whether these categories hold true for weekends,
for off-shifts, or at other facilities.
Next steps

Identifying the types and frequencies of interruptions is the


rst step to developing strategies to reduce interruptions.
Future research will focus on evaluating the chosen
improvement strategys effect on patient ow, nurses job
satisfaction, and the length of time it takes to accurately triage
patients. In the next phase of this project, we plan to look at
the amount of time consumed by interruptions and explore
the effect that interruptions have on patient outcomes.
Additional planned research includes replicating this
study in diverse facilities to determine whether the
frequencies and types of interruptions are consistent with
the results of this study. We plan to expand the sampled days
to include weekends, as well as afternoon and night shifts.
Future studies could focus on identifying relationships
between interruptions and the triage nurses ability to return
to a task and the triage nurses concentration, as well as the
effect this has on patient outcomes and perceived quality of
care. Exploring the accuracy of the triage and the time it
requires to triage a patient would be an appropriate metric
to investigate.

interruptions were investigated (ie, operating room, postanesthesia care units, and inpatient medication administration), links have been made that have shown patient care to be
adversely affected. There is sparse information on how
interruptions in triage affect patients or staff. When one
considers the fact that ED triage is the entry into the health
care system, this is especially surprising. With the limited
information available on the causes and implications of
interruptions in ED triage, more research needs to be
conducted to explore this phenomenon. The relatively
unexplored area of triage interruptions needs further investigation to ensure patient safety and privacy and to ensure that
optimal care is being provided for emergency patients.
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Conclusion

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Previous research has shown that interruptions have a negative


impact on concentration and perceived quality of care, as well
as increasing in error rates. In other studies in which

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