Main text
Extending visiting hours in adult intensive care units (ICUs) promotes family-centered care, but physicians may be concerned about increased distractions from visitors [
1]. We sought empirical evidence within our 20-bed medical ICU, assuming that distractions could cause medical errors [
2].
During office hours (07.30 to 17.30 on weekdays; 07.30–12.30 on weekends), two physician teams shared the patient load. Each team comprised one attending physician, one senior resident, and two junior residents. Observations of residents, being front-line medical staff, were performed during two time periods, before and after implementation of extended visiting hours in 2015. For each time period, observations were performed by different groups of six nurse researchers, following a standard method [
3]. For each observation session lasting 150–180 min, a pair of observers (A and B) independently recorded the duration, type, source, and severity of distractions. Distractions were defined as breaks in attention, evidenced by observed behaviour such as orienting away from a task or responding verbally [
4]. Analysis was based on the data of observer A only, while reliability was assessed using the data from observer B. All physicians gave informed consent to be observed, and no one declined participation. Ethics approval was obtained (DSRB/2011/00279).
From 11 May to 26 June 2011 (previously reported [
3]), visiting hours were restricted to 12.00–14.00 and 17.00 to 20.00 (total 5 h), and from 8 May to 9 July 2017, visiting hours were extended to 09.00–21.00 (total 12 h). Mean distraction frequency did not differ between both time periods (4.36 ± 2.27/h versus 5.00 ± 2.68/h,
t test
P = 0.262), even after adjusting for resident seniority using multiple linear regression (
P = 0.303). The distribution of current activities and distraction characteristics differed, though predominant type, sources, and severity of distractions were similar (Table
1). The duration of distractions was short, and median duration per distraction was shorter in the later time period (2 min versus 1 min,
P < 0.005). Reliability, as assessed by agreement of all observed distractions between observers A and B, was excellent in both time periods (99.1% and 96.1%, respectively).
Table 1
Characteristics of distractions
Sessions observed | 38 | 39 | NA |
Total observation time, h | 100.4 | 117 | NA |
Number of distractions | 444 | 585 | NA |
Start time of sessions observed |
Morning (07.30–12.00), n (%) | 23 (60.5) | 21 (53.8) | 0.554 |
Afternoon (12.00–17.30), n (%) | 15 (39.5) | 18 (46.2) |
Frequency of distractions/h, mean ± SD | 4.36 ± 2.27 | 5.00 ± 2.68 | 0.262 |
Distraction duration (min), median (IQR) | 2 (2–4) | 1 (1–2) | < 0.001 |
Current activity at the time of distraction, n (%) | < 0.001 |
Writing notes | 97 (21.8) | 150 (25.6) | |
Conducting ward round | 84 (18.9) | 35 (6.0) |
Entering treatment orders | 75 (16.9) | 148 (25.3) |
Reading notes | 61 (13.7) | 162 (27.7) |
Talking to a colleague | 47 (10.6) | 49 (8.4) |
Examining a patient | 37 (8.3) | 11 (1.9) |
Entering medication orders | 14 (3.2) | 3 (0.5) |
Performing non-sterile procedure | 11 (2.5) | 7 (1.2) |
Performing sterile procedure | 9 (2.0) | 9 (1.5) |
Talking to a patient | 3 (0.7) | 4 (0.7) |
Talking to a patient’s relative | 3 (0.7) | 6 (1.0) |
Performing resuscitation | 2 (0.5) | 0 (0.0) |
Giving medications | 1 (0.2) | 1 (0.2) |
Type of distraction, n (%) | <0.001 |
Asked to speak to colleague | 177 (39.9) | 367 (62.7) | |
Asked to write treatment orders | 61 (13.7) | 43 (7.4) |
Asked to attend to a patient | 61 (13.7) | 25 (4.3) |
Asked to sign a document | 31 (7.0) | 5 (0.9) |
Going to the toilet/going elsewhere | 30 (6.8) | 89 (15.2) |
Asked to perform a procedure | 29 (6.5) | 7 (1.2) |
Asked to speak to a patient’s relative | 25 (5.6) | 18 (3.1) |
Drinking/eating | 21 (4.7) | 14 (2.4) |
Asked to write medication orders | 7 (1.6) | 13 (2.2) |
Asked to administer medications | 2 (0.5) | 4 (0.7) |
Source of distraction, n (%) | 0.026 |
Other doctor | 156 (35.1) | 207 (35.4) | |
Nurse | 135 (30.4) | 147 (25.1) |
Self | 83 (18.7) | 164 (28.0) |
Phone call | 30 (6.8) | 28 (4.8) |
Other healthcare worker | 24 (5.4) | 21 (3.6) |
Relative | 14 (3.2) | 15 (2.6) |
Patient | 1 (0.2) | 2 (0.3) |
Monitor alarm | 1 (0.2) | 1 (0.2) |
Severity of distraction, n (%) | <0.001 |
No effect on activity | 13 (2.9) | 82 (14.0) | |
Momentary pausea
| 136 (30.6) | 193 (33.0) |
Complete pauseb
| 210 (47.3) | 288 (49.2) |
Abandons activity, attends to distraction | 85 (19.1) | 22 (3.8) |
Overall, distractions among ICU doctors were common (~4–5 distractions/doctor/h), and this is consistent with data from other studies using different observation methods [
5]. There was also no significant increase in the frequency of distractions after implementation of extended visiting hours in the ICU. Being asked to speak to family members constituted a small proportion (<5%) of the distractions, and therefore our study did not provide empirical support for the concern of increased distractions from visitors due to extended visiting hours.
Acknowledgements
The authors would like to thank the research nurses from Ngee Ann Polytechnic, Singapore, for assisting with the data collection.
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