Work Allocation and Task Switching Behaviors Among Pediatric Emergency Providers

Acute care for children is increasingly concentrated in pediatric emergency departments (EDs). Adult EDs have used observational methods to inform staffing and safety efforts, but analogous data in pediatric EDs is limited. This study aimed to characterize pediatric ED provider time allocation and task switching behaviors.

We conducted a time-motion study (Oct-Nov 2022) in a tertiary children’s hospital ED. Thirty-five providers [7 attendings, 22 nurses (RNs), 4 trainees, and 2 nurse practitioners (NPs)] were observed in 4-hour sessions. Trained staff recorded tasks and patients managed in 1-minute increments supplemented by field notes. We employed a mixed-methods analysis to summarize quantitative data and code qualitative notes.

Over 174 hours, providers performed 4,179 tasks (74.7% patient-related) to care for 323 patients. For patient-related tasks, attendings spent the most time on Emergency Severity Index (ESI) 3 patients (median 19.5 min [IQR 12.0-26.0]), followed by ESI 1-2 (13.5 [6.0-22.0]) and 4-5 (9.0 [8.0-21.5]). RNs spent the most time on ESI 1-2 patients (24.0 [8.0-71.0]), followed by ESI 4-5 (20.0 [11.0-28.0]), and 3 (18.5 [15.0-40.0]). Trainees spent the most time on ESI 3 patients (29.0 [19.0-58.0]). Providers allocated the most time to direct care (35.1%). Attendings allocated more time to communication/coordination (29.3%) than others (trainees 23.9%, NPs 16.9%, RNs 8.8%). The share of time spent on communication/coordination was higher for ESI 3 patients (25.5%) than ESI 1-2 (21.3%) and 4-5 (14.1%). Attendings allocated more time to evaluation as acuity decreased (ESI 1-2 23.2%, ESI 3 33.7%, ESI 4 38.5%). Nurses allocated less time to interventions as acuity decreased (ESI 1-2 34.1%, ESI 3 27.7%, ESI 4-5 22.5%). Attending median task-switch rates were 4.0/h [IQR 2.0-6.0] for ESI 1-2 patients and 7.5/h [4.0-10.0] for ESI 3. Median hourly task-switch rates among nurses were higher for ESI 1-2 patients (7.5 [4.0-13.3]) than 3 (6.0 [3.0-11.0]). Qualitative data identified role clarity, communication, and systems processes as intervention targets to enhance care quality and efficiency.

Provider time allocation and task‑switching patterns vary by both role and patient acuity. These findings identify unique demands of pediatric emergency care and opportunities to optimize staffing, streamline care processes, and improve care quality.