Using the Word “Quiet“ in the ED

Background: For those who believe in superstition, the superstitious belief that saying the word “quiet” while working in the ED will result in a calamitous surge of patients is a real concern. We reviewed a study from 2019 performed in a microbiology lab, that found no evidence of this superstition (Link is HERE).

Paper: Geller JE et al. The Use of the Word “Quiet” in the Emergency Department is not Associated with Patient Volume: A Randomized Controlled Trial AJEM 2022. PMID: 35339973 [Access on Read by QxMD]

Clinical Question: Is the use of the word “quiet” in the emergency department associated with ED crowdedness?

What They Did:

• Randomized clinical trial at a single US ED
  • Intervention: Asking “Has it been a quiet in here?”
  • Control: Greeting ED staff without saying the intervention phrase
• 14 days were randomly assigned the word “quiet” and 16 were not assigned the word “quiet”
• 3 hours after intervention or control, researchers administered a survey to all staff initially approached

Outcomes:

• All outcomes were based on a Visual Analog Scale ranging from 0 to 100):
  • Where would you say is your feeling toward how crowded the ED is?
  • Where would you say is your feeling toward how many patients have entered the ER over the past few hours?
  • Where on this scale is your belief that the use of the word “quiet” subsequently plays a role in how busy the rest of the day gets? 

Results:

• Collected 506 surveys
• Survey Question 1 (Crowded)
  • Intervention: 60.2
  • Control: 53.5
  • P = 0.27
• Survey Question 2 (Patient Number)
  • Intervention: 58.5
  • Control: 51.8
  • P = 0.24
• Survey Question 3 (Word “Quiet”)
  • Intervention: 51.3
  • Control: 56.3
  • P = 0.32
• Perception of the Word Quiet (With Intervention)
  • Survey Question 1 (Crowded)
    • Lower: 56.2
    • Higher: 68.6
    • P <0.0001
  • Survey Question 2 (Patient Number)
    • Lower: 53.8
    • Higher: 69.9
    • P <0.0001
• Perception of the Word Quiet (With Control)
  • Survey Question 1 (Crowded)
    • Lower: 51.7
    • Higher: 8
    • P = 0.92
  • Survey Question 2 (Patient Number)
    • Lower: 51.1
    • Higher: 52.0
    • P = 0.87

Strengths:

• Randomization was blinded to the statistician and primary investigator
• Questions a common bias in the human mind associating the word “quiet” with increase in work volume

Limitations:

• Convenience sample of 47 shifts spanning 30 days could affect results (i.e. majority of shifts were from morning to evening, with only 3 night shifts)
• Same researcher conducted the study each shift, so it is possible that the researcher began to become associated with the word “quiet”
• Several staff members participated more than once. This was not controlled for in the statistical analysis
• Small, single site study and therefore results may not be generalizable

Discussion:

• On the days the word “quiet” was used, those who believed in the superstition rated the ED as more crowded and as having more patients than those who did not believe the superstition. This was not the case when the word “quiet” was not used. As a matter of fact the volume of patients were in fact the same.
• There are several other trials that have come to similar conclusions in the literature:
  • Orthopedics: Lamb J et al. Does the Word ‘Quiet’ Really Make Things Busier? Bulletin. 2017 (Link is HERE)
    • This was a positive study but lots of issues with the paper including unblinded, convenience sample, no sample size calculation, and the outcome of admission is subjective
  • Microbiology Lab: Brookfield CR et al. Q Fever – The Superstition of Avoiding the Word “Quiet” as a Coping Mechanism: Randomised Controlled Non-Inferiority Trial. BMJ 2019. PMID: 31852676
    • No difference
  • Pediatric ED: Johnson G et al. The Q**** Study – Basic Randomised Evaluation of Attendance at a Children’s Emergency Department. EMJ 2010. (Link is HERE)
    • Unfortunately, only available as an abstract
    • No difference
  • ED: Kuriyama A et al. Impact of Attending Physicians’ Comments on Residents’ Workloads in the Emergency Department: Results from Two J(^o^)PAN Randomized Controlled Trials. PloS one 2016. PMID: 27936189
    • Two studies in one
    • Both showed no difference

Author Conclusion: “The use of the word “quiet” was not associated with increased patient volumes or the perception of increased patient volumes unless a staff member had a pre-existing belief the word “quiet” does influence your perception of emergency department volume.”

Clinical Take Home Point: Despite some of the limitations of this study, the use of the word “quiet” is not associated with increased patient volumes. However, those who believe in the superstition perceive the department to be busier even when it is not. Bias and chance alone can produce confirmatory results when no real effect exists. 

References:

1. Geller JE et al. The Use of the Word “Quiet” in the Emergency Department is not Associated with Patient Volume: A Randomized Controlled Trial AJEM 2022. PMID: 35339973 [Access on Read by QxMD]

For More Thoughts on This Topic Checkout:

• REBEL EM: The Q Word Superstition

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)