Interruptions are, in a way, the currency of emergency medicine. But many of them may be making patient care worse rather than safer. EKGs are a perfect example: physicians may be interrupted thousands of times each year so that every tracing receives immediate attention, even when the overwhelming majority do not represent an emergency. Protecting physician attention doesn’t have to come at the expense of quickly identifying patients who need immediate intervention.
In this episode, we explore how one emergency department dramatically reduced unnecessary EKG interruptions, why a 10-minute interpretation window may be safer than reflexively interrupting physicians, and how local data helped turn a counterintuitive idea into departmental practice. We also examine how asynchronous communication, protected workspaces, nursing partnerships, and a different way of thinking about attention can create a safer and more intentional emergency department.
Guest Bio: Dr. Jake Zadra is a board-certified Emergency Physician and the current Chair of the Department of Emergency Medicine and Diagnostics at St. Mary’s Hospital in Janesville, WI, where he also serves as Vice Chief of Staff. He completed medical school (’18) and EM residency (’21) at the University of Wisconsin, where he served as chief resident. Outside of medicine, he’s a live music enthusiast, enjoys slipping Lord of the Rings references into everyday conversation, and spends as much time outdoors as possible. He remains one of the few Emergency Physicians with no interest in ultramarathons or BASE jumping.
Here are the slides Jake used when presenting his idea to reduce interruptions in his emergency department
We Discuss:
Why Every EKG Doesn’t Need to Be an Emergency
EKGs are a predictable and frequent source of interruption in emergency medicine. In many EDs, the standard workflow is for every newly obtained EKG to be brought directly to a physician for immediate interpretation, regardless of what the tracing shows or how stable the patient appears. That means a physician may be interrupted while writing orders, talking with a patient or family, performing a procedure, or working through another cognitively demanding task.
Jake’s ED questioned whether every EKG truly requires that level of immediacy. For stable patients whose EKG does not trigger a machine-generated STEMI alert, the tracing is placed in a designated “EKG drop zone” beside the physician workstation. The physician reviews it within 10 minutes of acquisition, creating enough time to finish the current task before shifting full attention to the EKG.
Urgent findings still trigger an immediate interruption. A machine-flagged STEMI, a patient who appears sick or has unstable vital signs, or concern from anyone on the care team is enough to bring the EKG directly to the physician. The goal is not to make EKGs less important; it is to distinguish between those that require attention right now and those that can safely wait a few minutes for a more focused interpretation.
The Cost of 7,000 Interruptions to Find Two Unflagged STEMIs
The department’s own numbers made the scale of the tradeoff striking. In a year with roughly 23,000 emergency department visits, more than 7,000 EKGs were performed, and 15 STEMIs were diagnosed. The computer identified 13 of those 15, meaning physicians had faced more than 7,000 immediate EKG interruptions to identify two STEMIs that the machine had not already flagged.
Framed loosely as a “number needed to treat,” that works out to more than 3,500 interruptions for each additional STEMI identified at arrival. The redesigned workflow accepts the possibility that an unflagged case might be recognized at minute nine or ten rather than minute three or four, while potentially preventing thousands of disruptive task switches that affect care throughout the department.
What Happens When the EKG Machine Misses a STEMI
The two supposedly “missed” STEMIs make the story more nuanced. On retrospective review, neither tracing technically met traditional STEMI criteria for the required degree of ST elevation, although both patients had occlusion myocardial infarctions and were appropriately taken to the cath lab.
The physicians recognized clinically important findings beyond what the computer was programmed to flag, reinforcing why machine interpretation is being used as a triage mechanism rather than a replacement for physician interpretation. The workflow still guarantees physician review; it simply allows that review to occur within a short predefined window rather than demanding an immediate cognitive switch for every tracing.
Why Fewer Interruptions May Lead to Better EKG Interpretation
Immediate interpretation can create another problem: physicians may glance at an EKG primarily to answer the binary question of “STEMI or no STEMI” while simultaneously trying to preserve whatever thought or procedure was interrupted. That environment makes it harder to scrutinize a tracing for subtler abnormalities, STEMI equivalents, or findings consistent with an occlusion myocardial infarction.
Allowing a physician to finish an order set, complete an H&P, finish a phone call, or leave a patient room before turning fully to the EKG may delay interpretation by only a few minutes while improving the quality of that interpretation. The same EKG can receive more attention when it becomes the physician’s primary task rather than an intrusion into another cognitively demanding task.
How the Workflow Handles Gray-Zone EKGs
A non-STEMI tracing can contain dangerous findings such as high-grade heart block or ventricular tachycardia, so the workflow cannot depend solely on a computer’s STEMI flag. Clinical appearance serves as an additional safety net: a patient whose presentation worries a nurse or technician still generates an immediate interruption.
A stable patient with an unusual tracing may have the EKG placed in the drop zone, where it is reviewed within 10 minutes. The system therefore prioritizes physiologic instability and frontline concern rather than treating every abnormality on paper as requiring the same degree of immediacy.
Rethinking the 10-Minute EKG Rule
The 2025 ACC/AHA guideline recommends that an EKG “should be acquired and interpreted within 10 minutes of first medical contact” for patients with suspected ACS. The goal is rapid recognition of acute coronary occlusion, but that recommendation has often been operationalized as a requirement to immediately interrupt a physician every time an EKG prints.
Jake’s ED questioned whether the guideline actually requires that workflow. “First medical contact” leaves room for interpretation, and no evidence establishes minute nine as safe and minute 11 as dangerous. More importantly, emergency physicians are simultaneously managing STEMI, stroke, trauma, sepsis, procedures, unstable patients, and consultations. Optimizing one disease-specific metric by creating thousands of interruptions may introduce risk elsewhere.
The goal, then, is not to disregard the guideline but to separate its clinical objective from the workflow traditionally used to achieve it. Rapid recognition of patients who need urgent intervention remains essential; automatically interrupting a physician for every EKG may not be.
Using Local Data to Build a Safer Workflow
Jake brought the proposed change through his ED’s normal leadership structure, using local data on EKG volume, STEMI prevalence, machine performance, and interruption frequency to make the case. Concerns included delayed STEMI recognition, missed machine interpretations, EKGs getting lost before review, and potential effects on STEMI treatment or transfer times. Those risks were weighed against the potential harm of more than 7,000 EKG interruptions each year. The discussion ultimately won over initially skeptical leadership.
That experience does not mean every ED should replicate Jake’s policy. The more useful lesson is to replicate the process: examine local EKG volume, STEMI prevalence, machine performance, staffing, culture, and escalation reliability, then determine which interruptions truly require immediate attention. The safest workflow may look different from one ED to another.
How an EKG Drop Zone Keeps Deferred Reviews From Getting Lost
One concern with eliminating immediate physician handoffs is that an EKG could disappear into the operational equivalent of purgatory. The department addressed that risk with an intentionally simple physical design: an EKG-sized rectangle is taped beside every physician workstation and labeled with the goal of interpretation within 10 minutes.
The tracing has a single obvious destination, and the visual cue repeatedly reminds physicians that an EKG is waiting. Months into the new workflow, no EKG was known to have been lost because of the process.
The solution demonstrates that reducing interruptions does not mean relying on memory. It means replacing an interruptive reminder with a reliable, visible system.
How a Quieter Workspace Reduces Drive-By Interruptions
EKGs were only one source of interruption, so the department also changed its physical environment. Physician workstations were moved roughly 20 steps away from the center of the ED into a quieter room with a door, close enough to respond immediately to emergencies but far enough away to reduce casual drive-by questions.
Questions such as whether a patient can have water no longer have to penetrate a physician’s concentration simply because the physician happens to be physically accessible. The goal is not to create a “physician bunker,” but to recognize that proximity generates interruptions and that thoughtful workspace design can preserve emergency responsiveness without making clinicians perpetually available for every nonurgent question.
Why Not Every Interruption Deserves the Same Response
A patient who stops breathing and a request for acetaminophen are both pieces of information, but they should not enter a physician’s cognitive workflow in the same way. Building an interruption-conscious culture begins by explicitly telling staff what should interrupt a physician immediately and making it clear that urgent interruptions are welcome.
Lower-acuity questions can then be routed through asynchronous systems instead. This avoids creating a culture in which staff becomes reluctant to interrupt at all; the objective is selective interruption, where urgency determines how information travels.
How Secure Chat Can Become an Asynchronous Inbox
Epic Secure Chat can become another source of interruption when every message generates a pop-up, sound, or other notification, but it can also function as a queue of nonurgent work. By disabling most notifications and leaving only the small visual indicator that a new message has arrived, clinicians can decide when to open Secure Chat rather than having Secure Chat decide when they must switch tasks.
Questions about medications, oral intake trials, and other nonemergent issues accumulate until the physician reaches an appropriate break point. Several requests can then be handled together.
This transforms communication from repeated forced task switching into deliberate batching, allowing the physician to complete orders, documentation, consultations, and other cognitively demanding work before turning attention to a queue of tasks that can safely wait.
Why Nurses Need Protection From Interruptions Too
Attention is not exclusively a physician resource. Nurses perform complex cognitive work, prepare high-risk medications, manage unstable patients, and are vulnerable to the same consequences of unnecessary task switching.
The interruption-reduction initiative therefore works in both directions. Physicians are expected to use asynchronous communication for nonurgent nursing questions rather than interrupting a nurse who may be preparing a critical medication or completing another high-risk task. Existing protected medication spaces, including the locked room containing the Pyxis, reinforce the same principle.
Framing interruption reduction as a bidirectional patient-safety project also helps prevent the initiative from becoming “doctors asking everyone to leave them alone.” Protecting attention becomes a shared departmental expectation rather than a privilege afforded to one profession.
How Making Interruptions Visible Creates Buy-In
One of the biggest barriers to changing interruptions is that emergency clinicians often stop noticing them. Constant interruptions become part of the background of the job, and what would seem absurd in another high-stakes profession becomes accepted as unavoidable in emergency medicine.
A useful starting point is simply noticing each interruption again and asking whether it was emergent, whether it could have waited several minutes, and whether it improved or interfered with patient care. Once the cumulative burden becomes visible, reducing unnecessary interruptions can become easier to frame as a safety initiative rather than a clinician-comfort initiative.
As the conversation puts it, we can end up with a workday “governed by interruptions rather than intention.” Recognizing that pattern is the first step toward changing it.
Why the Messenger Can Determine Whether a Good Idea Survives
Data alone are not enough to change departmental culture. An initiative centered on reducing physician interruptions can easily be heard as “leave me alone” or as physicians trying to build themselves a bunker, particularly when it is delivered by someone whose communication style is naturally dry, direct, or provocative.
Successful implementation requires framing the change around benefits to patients and the entire ED staff. It can also mean partnering with people who have different relationships and communication styles, having informal conversations before the formal meeting, and first asking stakeholders about their experiences rather than arriving with a stack of data and declaring that something needs to change.
A good idea does not need to remain attached to the person who conceived it. Choosing a better messenger, strategically delegating, and building partnerships can determine whether an initiative that previously failed ultimately succeeds.
How Nursing Partnership Turns Policy Into Culture
Physician enthusiasm cannot create a department-wide communication culture on its own. A trusted nursing leadership partner can interrogate a proposed change, identify problems physicians may not see, translate the rationale for frontline staff, and make clear that the goal is aligned with nursing priorities rather than imposed on nursing workflow.
Strong dyad leadership helps reconcile perspectives. Nursing leadership can challenge the proposal and make it better, then communicate the resulting change in language that resonates with the people responsible for carrying it out every day.
Why Attention Should Be Treated as a Finite Patient-Safety Resource
Emergency departments already treat beds, ventilators, nurses, and physicians as finite resources, yet attention is often treated as infinitely divisible. It is not. Every unnecessary interruption consumes attention, creates a task switch, and forces a clinician to reconstruct the context of whatever was happening before the interruption.
The larger argument behind the EKG project is therefore much broader than EKGs: “Start thinking of attention as a finite resource, too, because it affects patient care, and protecting it shouldn’t be viewed as a luxury. It should be treated as an equal pillar of patient safety.”
The goal is not an interruption-free emergency department—an impossibility in acute care—but a department in which interruptions happen because they are clinically necessary rather than simply because “that’s how we’ve always done it.”
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