Open Access

Effect of extended visiting hours on physician distractions in the ICU: a before-and-after study

Critical Care201721:243

https://doi.org/10.1186/s13054-017-1830-y

Received: 16 August 2017

Accepted: 29 August 2017

Published: 18 September 2017

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

Variables studied

Restricted visiting hours

Extended visiting hours

P value

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)

aActivity resumes during distraction

bActivity resumes only after distraction ceases

IQR interquartile range, NA not applicable, SD standard deviation

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.

Abbreviation

ICU: 

Intensive care unit

Declarations

Acknowledgements

The authors would like to thank the research nurses from Ngee Ann Polytechnic, Singapore, for assisting with the data collection.

Funding

None.

Availability of data and materials

The dataset used and analysed during the current study are available from the corresponding author on reasonable request.

Authors’ contributions

KCS, XYS, and HTA conceived the study, participated in the design, and collected the data. KCS performed the statistical analysis and drafted the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Ethics approval was obtained from the National Healthcare Group Domain Specific Review Board (ethics approval number DSRB/2011/00279). All participating physicians gave informed consent to be observed.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Authors’ Affiliations

(1)
Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital
(2)
School of Health Sciences, Ngee Ann Polytechnic

References

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Copyright

© The Author(s). 2017

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