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An experimental study on the impact of clinical interruptions on simulated trainee performances of central… Jones, Jessica; Wilkins, Matthew; Caird, Jeff; Kaba, Alyshah; Cheng, Adam; Ma, Irene W Y Feb 14, 2017

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RESEARCHAn experimental study onof clinical interruptions onchBackground interruptions was noted per case, [3] and on the medicale interrupted,l task [9], takeete tasks withcost of inter-d to be morer 5600 hospi-ated to con-ear.Jones et al. Advances in Simulation  (2017) 2:5 DOI 10.1186/s41077-017-0038-120.1 million central-line days per year occur on inpatientCanadaFull list of author information is available at the end of the articleCentral venous catheter (CVC) insertion is a com-monly performed procedure. In the USA, an estimated* Correspondence: ima@ucalgary.ca1W21C, University of Calgary, Calgary, Canada4Department of Community Health Sciences, University of Calgary, Calgary,unit, interruptions of healthcare professionals occurredat a rate of 14 times per hour [1], while physicians andnurses in the emergency room setting in a trauma centerwere observed to be interrupted more than ten timesper hour [2]. In the operating room, a mean of 50the impact of interruptions is such that, oncindividuals may forget to resume the originalonger to complete the task [10], or complhigher error rates [11–13]. Overall, the yearlyruptions to the hospital has been estimatethan US$51,000 per hospital [14]. With ovetals in the USA [15], interruptions are estimtribute to costs of over US$280 million per yInterruptions in healthcare are common and occur ubi-quitously. In an observational study of an intensive careward, interruptions were also frequently present [4–6].Given the limited working memory of individuals [7, 8],AbstractBackground: Interruptions are common in the healthcare setting. This experimental study compares the effects ofinterruptions on simulated performances of central venous catheterization during a highly versus minimallycomplex portion of the task.Methods: Twenty-six residents were assigned to interruptions during tasks that are (1) highly complex: establishingultrasound-guided venous access (experimental group, n = 15) or (2) minimally complex: skin cleansing (controlgroup, n = 11). Primary outcomes were (a) performance scores at three time points measured with a validatedchecklist, (b) time spent on the respective tasks, and (c) number of attempts to establish venous access.Results: Repeated measure analyses of variances of performance scores over time indicated no main effect of timeor group. The interaction between time and group was significant: F (2, 44) = 4.28, p = 0.02, and partial eta2 = 0.16,indicating a large effect size. The experimental group scores decreased steadily over time, while the control groupscores increased with time. The experimental group required longer to access the vein (148 s; interquartile range(IQR) 60 to 361 vs. 44 s; IQR 27 to 133 s; p = 0.034). Median number of attempts to establish venous access washigher in the experimental group (2, IQR 1–7 vs. 1, IQR 1–2; p = 0.03).Conclusions: Interruptions during a highly complex task resulted in a consistent decrement in performance scores,longer time required to perform the task, and a higher number of venous access attempts than interruptionsduring a minimally complex tasks. We recommend avoiding interrupting trainees performing bedside procedures.Keywords: Central venous catheterization, Attention, Interruption, Task performance and analysis, Medical errorstrainee performances ofcatheterizationJessica Jones1,2, Matthew Wilkins1,2,3, Jeff Caird1,2,4, Alysha© The Author(s). 2017 Open Access This articInternational License (http://creativecommonsreproduction in any medium, provided you gthe Creative Commons license, and indicate if( Accessthe impactsimulatedentral venousKaba1,4, Adam Cheng5 and Irene W. Y. Ma1,4,6*le is distributed under the terms of the Creative Commons Attribution, which permits unrestricted use, distribution, andive appropriate credit to the original author(s) and the source, provide a link tochanges were made. The Creative Commons Public Domain Dedication waiverro/1.0/) applies to the data made available in this article, unless otherwise stated.wards [16]. Although indicated for many medically illpatients, CVCs have associated complication risks, withan estimated complication rate of over 15% [17]. The in-sertion of CVCs is a challenge for many trainees, as theprocedure involves multiple steps [18, 19]. Further, whilethe use of ultrasound guidance is intended to improvepatient safety [20, 21], its use adds to the complexity ofthe procedure.Complex tasks have previously been shown to be moresusceptible to the effects of interruptions than simplertasks [22], and less experienced trainees are more sus-ceptible to interruptions than experienced physicians[23]. Given that many trainees at teaching centersperform ultrasound-guided CVC insertions [24], wehypothesize that trainees may be quite susceptible to in-terruptions and that disruption of their attentional focusmay compromise procedural performances, especiallyProtocolAt baseline, all consenting participants completed ademographic survey. Participants were then given stan-dardized instructions to place a CVC into the rightinternal jugular (IJ) vein using ultrasound guidance(SonixTOUCH, BK Ultrasound©) on a simulator (Gen IIUltrasound Central Line Training Model, Blue Phantom™),in a standardized procedure room. The participants wereinformed that the patient had chronic kidney disease andno peripheral intravenous access. One confederate nursingassistant was in the procedure room and provided assist-ance as requested by the participants. During the proced-ure, participants communicated with the patient, whosevoice was controlled by researchers in the adjacent controlroom behind a one-way mirror. The scenario was videorecorded using four camera angles, capturing views of theroom, procedure site, procedural tray, and ultrasoundJones et al. Advances in Simulation  (2017) 2:5 Page 2 of 7during critical aspects of the task. As such, this study,via the use of simulation, seeks to examine the impact ofinterruptions at two different time points in the proced-ure performed by medical trainees and evaluates the im-pact of these interruptions on procedural performances.Specifically, we hypothesize that interruptions during atask that is complex, compared to interruptions during atask that is low in complexity, will result a lower proced-ural performance score, longer time spent on theprocedural task, and a higher number of attempts to es-tablish venous access.MethodsParticipantsAll internal medicine residents (n = 98; postgraduate year(PGY)-1 to PGY-5) were invited to participate in thisstudy between December 2012 and October 2013.Fig. 1 The four camera views of the central venous catheterization procedprocedural tray (upper right), from the left showing the procedural site (lowscreen (Fig. 1). Postprocedure, all participants underwenta 30-min semi-structured interview on their strategies fordealing with interruptions.InterruptionParticipants were assigned to two groups in this study.Due to accidental violations in the randomization pro-cedure, the majority of the participants (85%) were notrandomized but assigned using unconcealed alternatinggroup assignment. In the control group, participantswere interrupted during a task that was felt to be low incomplexity: skin cleaning for the insertion site. In theexperimental group, participants were interrupted dur-ing a more complex task: establishing venous accessunder direct ultrasound guidance, where the interrup-tion occurred as soon as the venous access needle en-tered the simulated skin.ure, from the foot of the bed (upper left), from the right showing theer right), and the ultrasound screen (lower left)Jones et al. Advances in Simulation  (2017) 2:5 Page 3 of 7At the pre-defined task (i.e., at the time of skin clean-ing for the control group and at the time of venousneedle skin entry for the experimental group), a 5-sinterruption was introduced by a telephone call into theprocedure room, whereby the nursing assistant relayedthe message on the patient’s high potassium (7.9 mmol/L).An electrocardiogram indicating clinical severity (e.g.,peaked T waves and widened QRS) was available if re-quested by the participant. The nursing assistant wasinstructed to acknowledge all orders from the participantsexcept for intravenous orders, whereby the participantswere reminded that the patient had no intravenous access.As therapy for the hyperkalemia requires intravenous ac-cess, it is anticipated that the participants would need tocomplete the CVC task.OutcomesThe primary outcomes of interest were (1) overall per-formance of CVC insertion, (2) time spent on the re-spective tasks, and (3) number of attempts to establishvenous access. Secondary outcomes included resultsfrom the thematic analyses of the interviews.Performance of CVC insertionPerformance of CVC insertion was assessed using a 23-item checklist, modified from a previously published toolwith validity evidence, to ensure that the items were ap-plicable to our current task [25, 26].Items that were executed appropriately were given ascore of two, items that were not completed were givena zero, while items that were completed inappropriatelyor suboptimally were given a score of one. From thischecklist, four scores were generated, presented as apercentage:(1)Overall score: sum of checklist score.(2)Time 1 score: steps prior to and including cleaning.(3)Time 2 score: steps after cleaning until venousaccess establishment.(4)Time 3 score: remaining steps in the procedure.All performances were rated by a faculty (IM) withover 10 years of prior experience in rating CVC perfor-mances and previously demonstrated high inter-rater re-liability using a similar tool [26]. Blinding of the rater togroup assignment was not possible as the videos clearlyindicate when the interruptions occurred.Time spent on procedureCleaning time was defined as the time taken to clean theinsertion site. Time required to access the IJ vein was de-fined as the time from first needle puncture until suc-cessful venous access, as indicated by the removal of thesyringe for wire insertion.Number of attemptsThe number of attempts taken to establish venous accessusing the needle and syringe was recorded. Number ofattempts was recorded independently by two researchers(IM and MW). Inter-rater reliability for this measurewas high [intraclass correlation coefficient = 0.97, 95%confidence interval (CI) 0.93 to 0.99].Statistical analysesGroup differences were compared and analyzed in anintention-to-treat basis using standard parametric andnon-parametric techniques [27]. Construct validity ofthe checklist was assessed by comparing performancescores of junior trainees (PGY 1–2) with senior trainees(PGY 3–5): 71.7 ± standard deviation (SD) 22.8 vs.88.1 ± 5.9%, respectively; p = 0.028. Internal reliabilityof the checklist was assessed using Cronbach’s alpha(alpha = 0.88).After testing for the assumption of sphericity (notviolated, chi-square (2) = 0.89, p = 0.64, epsilon = 0.96),mixed repeated measure analyses of variances were con-ducted to assess for group differences on performancescores on the three time points. Partial eta squaredvalues are reported as measures of effect sizes and inter-preted as follows: <0.01 = small effect, <0.06 = mediumeffect, and >0.14 = large effect [28]. Significant inter-action between group and time was further exploredusing the Bonferroni adjustments.All performances were recorded and time coded withNoldus Recorder and Observer XT, version 11.0 (NoldusInformation Technology, Wageningen, the Netherlands).All analyses were performed using SAS 9.3 (SAS InstituteInc., Cary, NC) and PASW Statistics, version 18.0 (PASW,IBM Corporation, Somers NY).Qualitative data analysesInterview data was transcribed into NVivo, version 10(QSR International, Burlington, MA). Thematic contentanalysis was performed independently by two re-searchers (IM, JJ) [29]. Assigned codes were reviewedand coded several times to ensure the saturation ofthemes. Codes were then grouped together based onsimilarities and linkages to form broader categories.Agreement in coding was high (Kappa = 0.89; 95% CI0.87 to 0.90) [30]. Disagreement in coding was resolvedby consensus.ResultsTwenty-six participants completed the study protocol.Of these, 11 (42%) to the control group and 15 (58%)were assigned to the experimental group. There were nosignificant demographic differences between the twogroups (Table 1).Table 1 Baseline characteristics of 26 participantsaBaseline characteristic Control(skin cleansing)group n = 11Experimental(venous access)group n = 15p valuePostgraduate year levelb1 and 2 5 (56) 8 (62) 1.003 to 5 4 (44) 5 (38) –GenderMales 9 (82) 9 (60) 0.39Females 2 (18) 6 (40) –Months rotating in the intensive care unit0 or 1 7 (64) 7 (47) 0.392 or more months 4 (36) 8 (53) –Median no. of central venouscatheterization performed(interquartile range)3 (1–12) 3 (1–25) 0.51Mean self-rated ability to performprocedure (± standard deviation)c2.5 ± 1.2 2.9 ± 1.4 0.48aData presented as number (percentage) unless otherwise indicatedbJones et al. Advances in Simulation  (2017) 2:5 Page 4 of 7Performance outcomesOverall checklist scores did not differ between groups(control group 82.7 ± SD 8.7% vs. experimental group72.6 ± 23.4%; p = 0.16). Scores for the three timeMissing values occurred because not all participants answeredall questionscRated out of 6; where 1 = not competent to perform independently,6 = above average to perform independentlypoints are shown in Fig. 2. There was no significantmain effect of time or group assignment: F (2, 44) = 0.08,p = 0.92, partial eta2 = 0.004; F (1, 22) = 0.46, p = 0.50;partial eta2 = 0.021, respectively. However, the interactionFig. 2 Mean checklist scores at three time points for participants inthe control (skin cleansing) group (n = 11) and participants in theexperimental (venous access) group (n = 15). Error bars indicatestandard errorbetween time and group assignment was significant: F(2, 44) = 4.28, p = 0.02, partial eta2 = 0.16, indicating alarge effect size.Post-hoc pairwise comparisons were not significant(mean score difference [experimental group score –control group score] at time 1: 10.9 ± SD 10.5%, p = 0.31;time 2: −1.71 ± 5.0%, p = 0.73; time 3: −22.8 ± 11.7%,p = 0.06).Time spent on procedureMean cleaning time did not differ between the twogroups (control group 43 ± 17 s vs. experimental group37 ± 13 s; p = 0.33).Median time required to access the IJ vein was signifi-cantly longer in the experimental group (148 s; inter-quartile range [IQR] 60 to 361 vs. 44 s; IQR 27 to 133 s;p = 0.034).Number of attemptsThe median number of attempts to establish venousaccess was significantly higher in the experimentalgroup (2, IQR 1–7) than that of the control group (1,IQR 1–2), p = 0.03.Impact of interruptionsTwo participants in the experimental group (13%)punctured the carotid artery while none in the con-trol group did so. In the experimental group, tech-nical errors observed included: one participant failedto aspirate during needle advancement while dealingwith the interruption. Before and after the interrup-tion, this participant did not display this suboptimalneedle advancement technique. One participant leftthe needle open to air while managing the interrup-tion. These errors were not observed in the controlgroup.In the control group, two participants cleaned thesame area twice with the same sponge during the inter-ruption. Another participant missed cleaning the centerof the target area while being interrupted. These sub-optimal cleaning techniques were not displayed duringthe first cleaning attempt before the interruption, norwere these techniques observed in the experimentalgroup.Thematic analysisIn the interview, participants reported being interrupted,outside of this study, a median of once per procedure(IQR 0 to 2). Analyses from semi-structured interviewsrevealed that the participants reported using an averageof 4 ± SD 2 strategies in managing interruptions(Table 2). Task prioritization was the most commonlyreported strategy (n = 19; 73%).theEx“Ta“Ththr“Re“Ba“La“Th“Fo“D“Stan“TrproJones et al. Advances in Simulation  (2017) 2:5 Page 5 of 7Table 2 Strategies used to manage interruptions, as reported byStrategy No. (%) reported usingstrategyInternal strategiesTalk aloud 1 (4)Reorienting (not specified) 7 (27)Mental Checklist 4 (15)Recap last steps 4 (15)Mental bookmarking 2 (8)Physical layout of equipment 1 (4)Focus (not specified) 6 (23)Prioritizing tasks 19 (73)Concentrating on one thing at a time 9 (35)Delegating tasks 8 (31)Stop and think 6 (23)Ignoring interruption 2 (8)DiscussionOur study identified that although performance scoresdo not differ between groups, interruptions during theexperimental condition resulted in a number of seriousprocedural errors that were not observed in the controlgroup. Examples of these errors included carotid punc-ture, leaving the needle open to air, and failure to aspir-ate during needle insertion. Further, a number of errorsin cleaning technique were observed in the controlgroup. These errors were likewise not observed in theexperimental group, nor were they observed in the con-trol group prior to the interruption.Prior studies have examined the impact of interrup-tions on tasks such as peg or object transfer tasks andartificial distraction tasks, such as performing arithmetic[10, 31–33]. In these studies, distractions typically wereshown to result in a decrease in the performance of thedistracting task [31], the primary task [10, 32], or both[33]. However, there remains a need for further researchon the impact of interruptions on clinical outcomes[34–37]. To our knowledge, our study is the first to ex-plore the impact of interruptions using primary andStay calm 2 (8) “TrMaintaining accuracy of primary task 1 (4) “DMental chunks 1 (4) “MMultitask 2 (8) “ItboExternal StrategiesHurry primary task 3 (12) “MHanding over pager 3 (12) “CCommunication (not specified) 2 (8)26 participantsamplelking out loud: where am I, what is next?”ink about the order of the procedure in my mind. Continue to goough it and go back to the list.”trace the last few steps, the last three things, this is where I need to go.”nk your thoughts – try not to lose my spot in what I was doing.”y things out so I know where I am.”e most pressing issue is the one I will address.”cus on one thing at a time. Not good at multi-tasking.”elegate to the clerk.”op and decide if you should continue. Stop everything in a safe positiond decide.”ied to ignore it initially – questioned if I should continue with thecedure.”interruption tasks specific to the CVC procedure, a com-plex procedure that is commonly performed [16]. Ourresults identified technical errors as a result of interrup-tions. Further, the decrement in performance, timetaken, and number of attempts made was significantlyworse when the interruption occurred at a more compli-cated part of the procedure. Although our participantsreported employing multiple strategies to manage theimpact of interruptions, our results suggest that thesestrategies may be ineffective at preventing the negativeconsequences of interruptions. As such, limiting inter-ruptions for trainee performances of CVC may be war-ranted [37].Our study has a number of limitations. First, as asingle-centered study, the generalizability of our conclu-sions may be limited. Our trainees were relatively inex-perienced overall. Therefore, our results do not pertainto experienced proceduralists. Second, we did not assessthe performance on the interrupting task itself. Poten-tially, participants whose CVC tasks suffered the mostmay have dealt with the interrupting task the best. How-ever, since effective treatment for hyperkalemia requiredy to remain calm.”oing what needed to be done – do it right.”anage in moments, split up your work into manageable chunks.”was distracting – I didn’t have full attention on either task. Trying to doth…had 80% attention on the procedure.”ade me do it faster.”arry the pager for [those doing procedures]”Jones et al. Advances in Simulation  (2017) 2:5 Page 6 of 7an intravenous access, and none of the participantschose to place an over-the-needle catheter into the IJ (allchose to complete the entire CVC insertion), perform-ance on the interrupting task would have been immater-ial. Third, although our group assignment was initiallyintended to be randomized, due to accidental violationsin the randomization procedure, the majority of the par-ticipants were ultimately assigned in a non-randomizedfashion (i.e., alternating group assignment). However,baseline participant characteristics were similar in bothgroups and no significant baseline differences werefound in the two groups. Nonetheless, our study was notrandomized in nature and therefore, we cannot excludethe possibility that the two groups systematically differedfrom each other. Fourth, our raters were not blinded tothe group assignment and therefore are subject to po-tential bias. Further, we had duplicate raters only forsome, not all, outcome measures. However, on thosemeasures, our inter-rater reliability was high. Fifth, wedid not perform a sample size calculation. We ultimatelywere only able to recruit a convenience sample of 26participants, due to scheduling and availability issuesand the voluntary nature of our study. Future studiesshould consider an a priori sample size calculation basedon a single primary outcome. Sixth, we were unable todetermine the exact time delay attributable to the cogni-tive effects of the interruptions, as we did not ask theparticipants to perform a think-aloud protocol. Futurestudies may consider the use of such a protocol. Sev-enth, we were unable to detect a difference in perform-ance scores between groups, which may be a result ofusing a checklist which tended to award points for com-pleting steps successfully [38]. Potentially, the use of achecklist that specifically assesses for errors may be bet-ter suited to detect performance issues that arose as aresult of the interruptions [39].These limitations notwithstanding, overall, our studydemonstrated that CVC performances are significantlyimpaired by interruptions, especially during a highlycomplex task. We therefore argue for the need to pre-vent these interruptions and/or develop effective strat-egies to assist trainees in mitigating the negative effectsof interruptions on procedural performances. Previousstudies have shown that visible signage and checklistsmay reduce the incidence of interruptions [37, 40]. Inanother study, the implementation of a “no interruptionzone” for nurses resulted in a significant decrease in thenumber of interruptions [41]. For CVC insertions, pagerhand-off could be considered to help minimize interrup-tions [42]. Nonetheless, some degree of interruption inhealthcare may be unavoidable. As such, systems-widestrategies for reducing the impact of interruptions needto be examined, and educators should consider traininglearners to deal with procedural interruptions.ConclusionsCVC performances are significantly impaired by inter-ruptions. We recommend that trainees performing CVCinsertions should not be interrupted during the proced-ure, especially during highly complex tasks.AbbreviationsCI: Confidence interval; CVC: Central venous catheter; IJ: Internal jugular;IQR: Interquartile range; PGY: Postgraduate year; SD: Standard deviationAcknowledgementsThe authors wish to thank the residents who participated in this study,Greg Hallihan and Dr. William Ghali for their feedback on the study protocol,Dr. Craig Speizali for his help with participant recruitment, and Dr. Tak Fungfor his assistance with the statistical analyses. Preliminary results from thisstudy were presented in abstract form at Human Factors and ErgonomicsSociety 2014 International Symposium on Human Factors and Ergonomics inHealth Care, March 16–19, 2014, Chicago, IL.FundingThis work was supported by the W21C Research and Innovation Centre,Western Economic Diversification Fund, and the Faculty of Arts. The fundingbody has no role in the study design; data collection, analysis, andinterpretation; the writing of the manuscript; or the decision to submit themanuscript for consideration for publication.Availability of data and materialsThe datasets generated and/or analyzed during the current study are notpublicly available but are available from the corresponding author onreasonable request.Authors’ contributionsJJ contributed to the study design, data analysis and interpretation, andwriting and critical revisions of the manuscript. MW contributed to the studydesign, data analysis and interpretation, and critical revisions of the manuscript.JC, AK, and AC contributed to the study design, data interpretation, and criticalrevisions of the manuscript. IWM contributed to the conception and design,data analysis and interpretation, and writing and critical revisions of themanuscript. All authors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publicationThe authors wish to thank Dr. Tara Cessford and Ms. Wrechelle Ocampo fortheir assistance with and consent for publication of the photographs.Ethics approval and consent to participateAll participants included in this study provided written consent. This studywas approved by the University of Calgary Conjoint Health Research EthicsBoard (Ethics ID number: E-24877).Author details1W21C, University of Calgary, Calgary, Canada. 2Department of Psychology,University of Calgary, Calgary, Canada. 3Faculty of Law, University of BritishColumbia, Vancouver, Canada. 4Department of Community Health Sciences,University of Calgary, Calgary, Canada. 5Department of Pediatrics, Universityof Calgary, Calgary, Canada. 6Department of Medicine, University of Calgary,3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada.Received: 7 December 2016 Accepted: 1 February 2017References1. Alvarez G, Coiera E. Interruptive communication patterns in the intensivecare unit ward round. Int J Med Inform. 2005;74(10):791–6.2. Brixey JJ, Tang Z, Robinson DJ, Johnson CW, Johnson TR, Turley JP, Patel VL,Zhang J. Interruptions in a level one trauma center: a case study. 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