Analyzing the time and value of housestaff inpatient work

Work Patterns and Intensity of Chinese Surgical Residents- A Multicenter Time-and-Motion Study

OBJECTIVE

This study aimed to record and analyze surgical resident trainee time allocation among junior doctors in China in order to understand the training environment and optimize realistic training and patient care objectives.

DESIGN

Multicenter observational time and motion study.

SETTING

Multicenter, carried out in 5 tier 3 public hospitals in 5 provinces across China.

PARTICIPANTS

Surgical resident trainees at various stages of training were eligible to enter the study, total n = 44. Registered nurses were eligible to be observers, n = 4 from each hospital.  An expert team comprising 4 chief surgeons and 10 surgical residents participated in establishing the clinical activity list.

RESULTS

Participants were observed during working hours (08.00-17.00) for 10 consecutive working days and time spent on different activities were recorded. Work patterns between hospitals were often dissimilar. Most time was spent on direct patient care (34.1%; 95% CI, 28.0%-40.1%) followed by indirect patient care (24.4%; 95% CI, 15.5%-33.2%), scholarly activity (21.1%; 95% CI, 13.7%-28.5%) and other (20.4%; 95% CI, 14.1%-26.8%). Subcategory analysis showed that the amount of time spent each day performing certain tasks was 137 minutes for operating theatre tasks, 103 minutes for medical record-keeping, 25 minutes for direct patient contact, 20 minutes being taught, 12 minutes teaching others, 12 minutes hand-over time, and 0 minutes of outpatient clinic attendance. Inter-observer reliability of 96.5% was obtained prior to recordings.

CONCLUSIONS

Chinese surgical resident work patterns fall within the range found in other international studies albeit with some exceptions. The training environment appears broadly suitable for competence-based surgical training in China. Inadequate outpatient activity has led to changes in trainee work rosters and trainer requirements. Both strengths and deficiencies were confirmed and addressed. Further audit is required.

Documentation as composing: how medical students and residents use writing to think and learn

Some educators have described clinical documentation as "scut". Research in medicine has focused on documentation's communicative value and not its function in learning. With time being an important commodity and electronic health records changing how we document, understanding the learning value of documentation is essential. The purpose of this study was to explore how trainee composing practices shape learning. Qualitative methods employing Rhetorical Genre Theory were used to explore clinical documentation practices among medical trainees. Data collection and analysis occurred in iterative cycles. Data included field notes and field interviews from 110 h of observing junior trainees and senior internal medicine residents participating in patient admission and follow-up visits. Analysis was focused on Paré and Smart's framework for studying documentation as composing. From a composing lens, documentation plays a vital role in learning in clinical settings. Junior trainees were observed to be reliant on using writing to support their thinking around patient care. Before patient encounters, writing helped trainees focus on what was already known and develop a preliminary understanding of the patient's problem(s). After encounters, writing helped trainees synthesize the data and develop an assessment and plan. Before and after the encounter, through writing, trainees also identified knowledge and data collection gaps. Our findings highlight clinical documentation as more than a communication task. Rather, the writing process itself appeared to play a pivotal role in supporting thinking. While some have proposed strategies for reducing trainee involvement, we argue that writing can be time well spent.

A Day in the Life of an Internal Medicine Resident - A Time Study: What Is Changed from First to Third Year?

BACKGROUND

In the past decade, internal medicine residencies have undergone major changes in competency-based assessments, work-hour restrictions and the implementation of the electronic medical record. The aim of this study is to compare a typical day of a first year post-graduate (PGY1) to that of a third year post-graduate (PGY3) internal medicine resident and examine if the differences in their days demonstrate the American Board of Internal Medicine's (ABIM) desired progression towards competency-based milestones and unsupervised practice.

METHODS

We conducted an observational time study documenting 14,103 minutes, 9 major categories, and 17 subcategories while shadowing 10 internal medicine PGY1s and 10 PGY3s during inpatient, non-call days. The following day, house staff completed surveys of their perceived time allocation of the previous 24 hours.

RESULTS

PGY1s spent an average of 12.5 hours managing an average of 6 patients. Thirty-eight percent of their time was spent on the computer, 21% discussing patients and 18% directly with patients. PGY3s, overseeing an average of 12 patients, worked 1.5 hours less per day (p<0.001), had 1.5 hours less computer time (p=0.001), 24 minutes less direct patient contact (p=0.045), and 36 minutes more patient care discussions (p=0.011).

CONCLUSION

The difference between PGY1s' and PGY3s' daily time allocations is minimal. Whereas a PGY3 spends 1.5 hours less than a PGY1 on writing computer notes and discharges, they also work 1.5 hours less per day. The additional 36 minutes of patient care discussions was the only significant time quantity difference that would be considered a higher level of practice for the PGY3 compared to the PGY1. With residents now caring for fewer patients, there has been a marked increase in computer time per patient for both PGY1s and PGY3s.

Estimating Time Physicians and Other Health Care Workers Spend with Patients in an Intensive Care Unit Using a Sensor Network

BACKGROUND

Time and motion studies have been used to investigate how much time various health care professionals spend with patients as opposed to performing other tasks. However, the majority of such studies are done in outpatient settings, and rely on surveys (which are subject to recall bias) or human observers (which are subject to observation bias). Our goal was to accurately measure the time physicians, nurses, and critical support staff in a medical intensive care unit spend in direct patient contact, using a novel method that does not rely on self-report or human observers.

METHODS

We used a network of stationary and wearable mote-based sensors to electronically record location and contacts among health care workers and patients under their care in a 20-bed intensive care unit for a 10-day period covering both day and night shifts. Location and contact data were used to classify the type of task being performed by health care workers.

RESULTS

For physicians, 14.73% (17.96%) of their time in the unit during the day shift (night shift) was spent in patient rooms, compared with 40.63% (30.09%) spent in the physician work room; the remaining 44.64% (51.95%) of their time was spent elsewhere. For nurses, 32.97% (32.85%) of their time on unit was spent in patient rooms, with an additional 11.34% (11.79%) spent just outside patient rooms. They spent 11.58% (13.16%) of their time at the nurses' station and 23.89% (24.34%) elsewhere in the unit. From a patient's perspective, we found that care times, defined as time with at least one health care worker of a designated type in their intensive care unit room, were distributed as follows: 13.11% (9.90%) with physicians, 86.14% (88.15%) with nurses, and 8.14% (7.52%) with critical support staff (eg, respiratory therapists, pharmacists).

CONCLUSIONS

Physicians, nurses, and critical support staff spend very little of their time in direct patient contact in an intensive care unit setting, similar to reported observations in both outpatient and inpatient settings. Not surprisingly, nurses spend far more time with patients than physicians. Additionally, physicians spend more than twice as much time in the physician work room (where electronic medical record review and documentation occurs) than the time they spend with all of their patients combined.

It's not just what you know: junior trainees' approach to follow-up and documentation

CONTEXT

In teaching hospitals, junior trainees (first-year residents and third-year medical students) are responsible for patient follow-up and documentation under the supervision of senior team members. In order to support trainees in their role, supervisors need to understand how trainees approach these tasks and how they can be coached to develop best practices.

OBJECTIVES

The purpose of our study was to explore the range of practices used by junior trainees in clinical settings.

METHODS

Constructivist grounded theory was used to guide the collection and analysis of data on follow-up and documentation during 34 observation periods with 17 junior trainees. Data sources included field notes, field interviews and de-identified copies of patient charts. We also held two focus groups with four attending physicians in each.

RESULTS

We were able to describe three interrelated characteristics that influenced a trainee's approach to and ability to perform the tasks of patient follow-up and documentation: (i) diligence; (ii) relationship to the team (dependent, independent, collaborative), and (iii) level of performance (Data Gatherer, Sensemaker, Manager). Diligence and relationship to the team appeared to influence the quality and focus of a trainee's approach at all levels of performance. Level of performance was felt, by focus group attending physicians, to reflect a developmental progression of knowledge and skills.

CONCLUSIONS

Our findings contribute to the existing literature in three ways. Firstly, they extend our understanding of how junior trainees approach the task of in-patient follow-up and clinical documentation and the value of those activities. Secondly, they provide new insights to support formative and summative assessment. Finally, they contribute to a growing body of literature exploring the factors that impact trainees' roles and interactions with the team. Future research should focus on validating our findings and exploring their utility in the development of novel assessment strategies.

More physicians in public health: Less public health work?

Aim: The object was to assess changes in work priorities in local public health medicine in Norway over the period from 1994 to 1999. Methods: Two cross-sectional studies were undertaken of physicians working in local public health medicine in all Norwegian municipalities, using a postal questionnaire. Results: Half of the physicians working in public health in 1999 were recruited after 1994. Although the number of physicians working in public health increased from 505 in 1994 to 555 in 1999 (10%) an estimation of the total weekly hours worked decreased by 3.7% from 8,715 hours in 1994 to 8,386 hours in 1999. The vast majority of physicians worked in combined posts (87%), and they reduced their engagement in public health by 2.6 hours on average from 1994 to 1999. The reduction depended on remuneration model, speciality in community medicine, and municipality size. Conclusions: Local public health in Norway was under pressure in the 1990s. For public health physicians, preventive medicine lost out to clinical work. No promising signals of change in the professional or political framework or in incentives for public health work are seen.

How Do Residents Spend Their Time in the Intensive Care Unit?

PURPOSE

To describe the work of residents and the distribution of their time in 6 intensive care units (ICUs) of 2 medical centers (MCs).

METHODS

A total of 242 hours of observation to capture data on tasks performed by residents in 6 ICUs, including adult, pediatric, medical and surgical units, were conducted. For each observation period, the percentages of total time spent on each task and on the aggregated task categories were calculated.

RESULTS

Overall, while in the ICUs, residents spent almost half of their time in clinical review and documentation (19%), conversation with team physicians (16%), conversation attendance (6%) and order management (6%). The 2 MCs differed in the time that residents spent on administrative review and documentation (4% in one MC and 15% in the other). The pediatric ICUs were similar in the 2 MCs, whereas the adult ICUs exhibited differences in the time spent on order management and administrative review and documentation.

CONCLUSIONS

While in the ICUs, residents spent most time performing direct patient care and care coordination activities. The distribution of activities varied across 2 MCs and across ICUs, which highlights the need to consider the local context on residents' work in ICUs.

Educating medical trainees on medication reconciliation: a systematic review

BACKGROUND

Effective medication reconciliation is critical in reducing the risk of preventable adverse drug events. Medical trainees are often responsible for medication reconciliation on admission, transfer and discharge of the most vulnerable patients; therefore, it is important that trainees are educated on this aspect of quality care.

METHODS

We conducted a systematic review using MEDLINE and EMBASE databases to identify education initiatives targeted at improving trainee skill and knowledge in carrying out medication reconciliation. Studies published in English or French between July 1980 and July 2013, where the primary focus of the article was the role of medical trainees in conducting medication reconciliation, and where trainee-specific data was reported, were included. Included articles must have reported trainee-specific data. Given the anticipated heterogeneity and array of outcomes, we were unable to employ a specific tool in assessing the risk of bias across studies.

RESULTS

Seven studies met pre-specified eligibility criteria, indicating the lack of published education initiatives targeted towards improving trainee knowledge and experience. Four described an education intervention targeted towards students completing internal medicine clerkship, while the remaining 3 were implemented among residents. Although no two interventions were the same, 5 out of 7 included an experiential component.

CONCLUSIONS

Varying success was achieved with medication reconciliation education interventions. While some noted improved competence and/or confidence amongst trainees, namely undergraduate medical students, others noted little effect resulting from the intervention.

Progressive collaborative refinement on teams: implications for communication practices

OBJECTIVES

Medical teaching teams (MTTs) must balance teaching and patient care in the face of three challenges: shifting team membership, varying levels of learners and patient complexity. To support care, MTTs rely on a combination of recurrent oral and written communication practices (genres), such as admission, progress and discharge notes. The purpose of this study was to explore how these genres influence the team's ability to collectively care for patients.

METHODS

This was a multiple case study with data collected through observations and audio-recordings of 19 patient cases focusing on admission review discussions and chart documents throughout the hospitalisation. Participants included 14 medical students, 32 residents and 10 attending physicians rotating through one of three internal medicine MTTs. We used constant comparative analysis to identify recurrent patterns across the multiple cases, which were further elaborated in a return-of-findings focus group.

RESULTS

The MTT genre system facilitated the care of patients through 'progressive collaborative refinement' (PCR): MTTs use case and data reviews to collaboratively and progressively refine their understanding of the patient's problems and develop strategies for addressing them. Progressive collaborative refinement was apparent through modifications made in the documentation. Although modifications were a necessary component, they were not sufficient: some modifications were made without refinement. We characterised incidents of failed modification as 'fragmentation'. Three types were observed: conceptualisation, documentation and continuity of care providers. In most cases, all three were present and interacted to impede PCR.

CONCLUSIONS

Progressive collaborative refinement was used by MTTs to provide the optimal care to patients. Progressive collaborative refinement was impeded by a lack of continuity of care providers and gaps between communication genres that fragmented conceptualisation and documentation. Progressive collaborative refinement can be understood as both an overarching process and a shared but unstated ideal. Through defining and describing PCR, the present findings can be used to improve communication and teaching.

Relationships of multitasking, physicians' strain, and performance: an observational study in ward physicians

BACKGROUND

Simultaneous task performance ("multitasking") is common in hospital physicians' work and is implicated as a major determinant for enhanced strain and detrimental performance.

OBJECTIVE

The aim was to determine the impact of multitasking by hospital physicians on their self reported strain and performance.

METHOD

A prospective observational time-and-motion study in a Community Hospital was conducted. Twenty-seven hospital physicians (surgical and internal specialties) were observed in 40 full-shift observations. Observed physicians reported twice on their self-monitored strain and performance during the observation time. Associations of observed multitasking events and subsequent strain and performance appraisals were calculated.

RESULTS

About 21% of the working time physicians were engaged in simultaneous activities. The average time spent in multitasking activities correlated significantly with subsequently reported strain (r = 0.27, P = 0.018). The number of instances of multitasking activities correlated with self-monitored performance to a marginally significant level (r = 0.19, P = 0.098).

CONCLUSION

Physicians who engage in multitasking activities tend to self-report better performance but at the cost of enhanced psychophysical strain. Hence, physicians do not perceive their own multitasking activities as a source for deficient performance, for example, medical errors. Readjustment of workload, improved organization of work for hospital physicians, and training programs to improve physicians' skills in dealing with multiple clinical demands, prioritization, and efficient task allocation may be useful avenues to explore to reduce the potentially negative impact of simultaneous task performance in clinical settings.

In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time?

BACKGROUND

The 2003 and 2011 Accreditation Council for Graduate Medical Education (ACGME) common program requirements compress busy inpatient schedules and increase intern supervision. At the same time, interns wrestle with the effects of electronic medical record systems, including documentation needs and availability of an ever-increasing amount of stored patient data.

OBJECTIVE

In light of these changes, we conducted a time motion study to determine how internal medicine interns spend their time in the hospital.

DESIGN

Descriptive, observational study on inpatient ward rotations at two internal medicine residency programs at large academic medical centers in Baltimore, MD during January, 2012.

PARTICIPANTS

Twenty-nine interns at the two residency programs.

MAIN MEASURES

The primary outcome was percent of time spent in direct patient care (talking with and examining patients). Secondary outcomes included percent of time spent in indirect patient care, education, and miscellaneous activities (eating, sleeping, and walking). Results were analyzed using multilevel regression analysis adjusted for clustering at the observer and intern levels.

KEY RESULTS

Interns were observed for a total of 873 hours. Interns spent 12 % of their time in direct patient care, 64 % in indirect patient care, 15 % in educational activities, and 9 % in miscellaneous activities. Computer use occupied 40 % of interns' time. There was no significant difference in time spent in these activities between the two sites.

CONCLUSIONS

Interns today spend a minority of their time directly caring for patients. Compared with interns in time motion studies prior to 2003, interns in our study spent less time in direct patient care and sleeping, and more time talking with other providers and documenting. Reduced work hours in the setting of increasing complexity of medical inpatients, growing volume of patient data, and increased supervision may limit the amount of time interns spend with patients.

The hybrid progress note: semiautomating daily progress notes to achieve high-quality documentation and improve provider efficiency

Health care institutions are moving toward fully functional electronic medical records (EMRs) that promise improved documentation, safety, and quality of care. However, many hospitals do not yet use electronic documentation. Paper charting, including writing daily progress notes, is time-consuming and error prone. To improve the quality of documentation at their hospital, the authors introduced a highly formatted paper note template (hybrid note) that is prepopulated with data from the EMR. Inclusion of vital signs and active medications improved from 75.5% and 60% to 100% (P < .001), respectively. The use of unapproved abbreviations in the medication list decreased from 13.3% to 0% (P < .001). Prepopulating data enhances provider efficiency. Interviews of key clinician leaders also suggest that the initiative is well accepted and that documentation quality is enhanced. The hybrid progress note improves documentation and provider efficiency, promotes quality care, and initiates the development of the forthcoming electronic progress note.

Students' workplace learning in two clerkship models: a multi-site observational study

CONTEXT

Longitudinal integrated clerkships (LICs) are established, rapidly growing models of education designed to improve the core clinical year of medical school using guiding principles about workplace learning and continuity. This study is the first to report data from direct observations of workplace learning experiences of students on LICs and traditional block clerkships (BCs), respectively.

METHODS

This multi-institution study used an observational, work-sampling methodology to compare LIC and BC students early and late in the core clinical year. Trained research assistants documented students' activities, participation (observing, with assistance, alone), and interactions every 10 minutes over 4-hour periods. Each student was observed one to three times early and/or late in the year. Data were aggregated at the student level and by in-patient or out-patient setting for BC students. One-way analysis of variance (anova) was used to compare two groups early in the year (LIC and BC students) and three groups late in the year (LIC, out-patient BC and in-patient BC students).

RESULTS

Early-year observations included 26 students (16 LIC and 10 BC students); late-year observations included 44 students (28 LIC, eight out-patient BC and eight in-patient BC students). Out-patient activities and interactions of LIC and BC students were similar early in the year, but in the later period LIC students spent significantly more time performing direct patient care activities alone (25%) compared with out-patient (12%) and in-patient (7%) BC students. Students on LICs were significantly more likely to experience continuity with patients as 34% of their patients returned to them, whereas only 5% of patients did so for out-patient BC students late in the year.

CONCLUSIONS

By late year, LIC students engage in patient care more independently and have more opportunities to see clinic patients on multiple occasions than BC students. Consistent with the principles of workplace learning, these findings suggest that yearlong longitudinal integrated education models, that rely mostly on ambulatory settings, afford students greater opportunities to participate more fully in the provision of patient care.

Defining and measuring the effort needed for inpatient medicine work

BACKGROUND

Current metrics for assessing physician workload are inadequate. Understanding the effort associated with work tasks could make workload assessments more robust.

OBJECTIVE

To assess the physical, mental, and psychological effort needed for the tasks performed by internal medicine doctors while admitting a patient to the hospital.

DESIGN

Cross-sectional survey.

SETTING

A single Midwest academic institution.

SUBJECTS

Internal medicine housestaff, hospitalists, and nonhospitalist internal medicine faculty.

MEASUREMENTS

Subjects rated 99 tasks across 3 domains: physical, mental, and psychological effort using a scale of 1-7 (1 = least effort, 7 = most effort). A composite effort score was calculated for each task and for each of 6 task categories: direct patient care, indirect patient care, searching for/finding things, educational/academic activities, personal/downtime activities, and other.

RESULTS

Overall, the most difficult task was going to codes, which was also the most difficult psychological task. The most difficult physical task was placing a central line, and the most difficult mental task was transferring an unstable patient to the intensive care unit. The easiest task was using the Internet. That was also the easiest physical, mental, and psychological task. Direct patient care was more difficult than indirect patient care overall (3.58 vs 3.21; P < 0.001).

CONCLUSION

We began the process of describing the workload of inpatient doctors by measuring the difficulty of the tasks they perform while admitting patients. To assess the relationship between workload and other outcomes (such as physician burnout and patient safety), it is essential that we be able to accurately measure workload.

Service census caps and unit-based admissions: resident workload, conference attendance, duty hour compliance, and patient safety

OBJECTIVE

To examine the effect of census caps and unit-based admissions on resident workload, conference attendance, duty hour compliance, and patient safety.

PARTICIPANTS AND METHODS

We implemented a census cap of 14 patients on 6 Mayo Clinic internal medicine resident hospital services and a unit-based admissions process in which patients and care teams were consolidated within hospital units. All 280 residents and 15,926 patient admissions to resident and nonresident services 1 year before the intervention (September 1, 2006, through August 31, 2007) and 1 year after the intervention (May 1, 2008, through April 30, 2009) were included. Residents' workload, conference attendance, and duty hours were tracked electronically. Patient safety variables including Rapid Response Team and cardiopulmonary resuscitation events, intensive care unit transfers, Patient Safety Indicators, and 30-day readmissions were compared preintervention and postintervention.

RESULTS

After the intervention, residents' mean (SE) ratings of workload appropriateness improved (3.10 [0.08] vs 3.87 [0.08] on a 5-point scale; P<.001), as did conference attendance (1523 [56. 8%] vs 1700 [63.5%] conferences attended; P<.001). Duty hour violations for working more than 30 consecutive hours and not having 10 hours off between duty periods decreased from 77 of 9490 possible violations (0.81%) to 27 (0.28%) and from 70 (0.74%) to 14 (0.15%) violations, respectively (both, P<.001). Thirty-day readmissions to resident services decreased (1010 [18.14%] vs 682 [15. 37%]; P<.001). All other patient safety measures remained unchanged. After adjustment for illness severity, there were no significant differences in patient outcomes between resident and nonresident services.

CONCLUSION

Census caps and unit-based admissions were associated with improvements in resident workload, conference attendance, duty hour compliance, and readmission rates while patient outcomes were maintained.

Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement

Recognizing the importance of teamwork in hospitals, senior leadership from the American College of Physician Executives (ACPE), the American Hospital Association (AHA), the American Organization of Nurse Executives (AONE), and the Society of Hospital Medicine (SHM) established the High Performance Teams and the Hospital of the Future project. This collaborative learning effort aims to redesign care delivery to provide optimal value to hospitalized patients. With input from members of this initiative, we prepared this report which reviews the literature related to teamwork in hospitals. Teamwork is critically important to provide safe and effective hospital care. Hospitals with high teamwork ratings experience higher patient satisfaction, higher nurse retention, and lower hospital costs. Elements of effective teamwork have been defined and provide a framework for assessment and improvement efforts in hospitals. Measurement of teamwork is essential to understand baseline performance, and to demonstrate the utility of resources invested to enhance it and the subsequent impact on patient care. Interventions designed to improve teamwork in hospitals include localization of physicians, daily goals of care forms and checklists, teamwork training, and interdisciplinary rounds. Though additional research is needed to evaluate the impact on patient outcomes, these interventions consistently result in improved teamwork knowledge, ratings of teamwork climate, and better understanding of patients' plans of care. The optimal approach is implementation of a combination of interventions, with adaptations to fit unique clinical settings and local culture.

Internal medicine residents' time study: paperwork versus patient care

BACKGROUND

Multiple factors affect residency education, including duty-hour restrictions and documentation requirements for regulatory compliance. We designed a work sampling study to determine the proportion of time residents spend in structured education, direct patient care, indirect patient care that must be completed by a physician, indirect patient care that 5 be delegated to other health care workers, and personal activities while on an inpatient general practice unit.

METHODS

The 3-month study in 2009 involved 14 categorical internal medicine residents who volunteered to use personal digital assistants to self-report their location and primary tasks while on an inpatient general practice unit.

RESULTS

Residents reported spending most of their time at workstations (43%) and less time in patient rooms (20%). By task, residents spent 39% of time on indirect patient care that must be completed by a physician, 31% on structured education, 17% on direct patient care, 9% on indirect patient care that 5 be delegated to other health care workers, and 4% on personal activities. From these data we estimated that residents spend 34 minutes per patient per day completing indirect patient care tasks compared with 15 minutes per patient per day in direct patient care.

CONCLUSIONS

This single-institution time study objectively quantified a current state of how and where internal medicine residents spend their time while on a general practice unit, showing that residents overall spend less time on direct patient care compared with other activities.

Patient acuity rating: quantifying clinical judgment regarding inpatient stability

BACKGROUND

New resident work-hour restrictions are expected to result in further increases in the number of handoffs between inpatient care providers, a known risk factor for poor outcomes. Strategies for improving the accuracy and efficiency of provider sign-outs are needed.

OBJECTIVE

To develop and test a judgment-based scale for conveying the risk of clinical deterioration.

DESIGN

Prospective observational study.

SETTING

University teaching hospital.

SUBJECTS

Internal medicine clinicians and patients.

MEASUREMENTS

The Patient Acuity Rating (PAR), a 7-point Likert score representing the likelihood of a patient experiencing a cardiac arrest or intensive care unit (ICU) transfer within the next 24 hours, was obtained from physicians and midlevel practitioners at the time of sign-out. Cross-covering physicians were blinded to the results, which were subsequently correlated with outcomes.

RESULTS

Forty eligible clinicians consented to participate, providing 6034 individual scores on 3419 patient-days. Seventy-four patient-days resulted in cardiac arrest or ICU transfer within 24 hours. The average PAR was 3 ± 1 and yielded an area under the receiver operator characteristics curve (AUROC) of 0.82. Provider-specific AUROC values ranged from 0.69 for residents to 0.85 for attendings (P = 0.01). Interns and midlevels did not differ significantly from the other groups. A PAR of 4 or higher corresponded to a sensitivity of 82% and a specificity of 68% for predicting cardiac arrest or ICU transfer in the next 24 hours.

CONCLUSIONS

Clinical judgment regarding patient stability can be reliably quantified in a simple score with the potential for efficiently conveying complex assessments of at-risk patients during handoffs between healthcare members.

Real-time assessment of nurse work environment and stress

Ecological momentary assessment methods were used to examine real-time relationships between work environment factors and stress in a sample of 119 registered nurses (RNs) in acute and critical care settings of three hospitals. The RNs carried handheld computers for 1 week of work shifts and were randomly surveyed within 90-min intervals to self-report work activity, perceived workload, and stress. Mixed effects linear regression analyses were completed to predict the stress score in the sample. The number of patients assigned significantly predicted stress; the greater the number of assigned patients, the higher the reported stress (p<.01). Age, gender, adult versus pediatric facility type, familiarity with patients, and proportion of direct care tasks were not significant predictors of stress. Further research is needed to link work environment factors and stress with errors among nurses.

Otolaryngology Resident Workflow

Objective. To investigate workflow in an otolaryngology–head and neck surgery residency program over 1 year and identify areas for improvement in the efficiency of resident education and training.

Study Design. Time-motion study.

Setting. An urban, county hospital and a Veterans Affairs medical center hospital.

Subjects and Methods. Eight otolaryngology residents (4 residents at postgraduate year [PGY] 2 and 4 at PGY 4) were studied using direct observations early and late in the 2008-2009 academic year. Resident activities were categorized, and a database program was generated for a handheld computer to facilitate time entry. Resident activities were classified into a taxonomy of tasks and their educational value was assessed. For each PGY level studied, observations were made for clinic and operative days.

Results. Residents spent their day on direct patient care (43.5%), indirect patient care (33.7%), didactic education (9.6%), personal activities (7.5%), and transit (5.8%), with activities of marginal educational value consuming 16% of their time. Major inefficiencies included managing administrative tasks, scheduling, and technical difficulties. On average, residents devoted significantly more time to marginal tasks on clinic days (19%) than on operative days (12%; P < .001). These data were compared with previously published data obtained during the pre–Accreditation Council for Graduate Medical Education (ACGME) duty hour mandates era.

Conclusion. This study evaluates resident workflow and efficiency over the course of a PGY in an ACGME-accredited otolaryngology residency program. By understanding the time motion of residents, interruptions and inefficiencies in workflow can be identified to direct future changes to enhance resident education and training in the era of the ACGME duty hours mandate.

Development of a hand-held computer platform for real-time behavioral assessment of physicians and nurses

We developed a hand-held data collection tool to facilitate real-time collection of data on the factors that affect hospital staff performance. To assure high-yield of data from busy clinicians, the design objectives included low response burden, the ability to collect complex real-time data in dynamic work environments, and automated data integration. Iterative user-centered design of custom interfaces resulted in a dynamic intuitive platform where branching logic was applied to present a series of survey questions dependent on the participant's responses. Over a 12-month period, 304 inpatient physicians and nurses completed (with minimal initial training) a total of 11,381 survey responses. For randomly timed repeated survey prompts, complete (73%) or partial (12%) responses were obtained in a median time of 96s.

Participant observation of time allocation, direct patient contact and simultaneous activities in hospital physicians

BACKGROUND

Hospital physicians' time is a critical resource in medical care. Two aspects are of interest. First, the time spent in direct patient contact - a key principle of effective medical care. Second, simultaneous task performance ('multitasking') which may contribute to medical error, impaired safety behaviour, and stress. There is a call for instruments to assess these aspects. A preliminary study to gain insight into activity patterns, time allocation and simultaneous activities of hospital physicians was carried out. Therefore an observation instrument for time-motion-studies in hospital settings was developed and tested.

METHODS

35 participant observations of internists and surgeons of a German municipal 300-bed hospital were conducted. Complete day shifts of hospital physicians on wards, emergency ward, intensive care unit, and operating room were continuously observed. Assessed variables of interest were time allocation, share of direct patient contact, and simultaneous activities. Inter-rater agreement of Kappa = .71 points to good reliability of the instrument.

RESULTS

Hospital physicians spent 25.5% of their time at work in direct contact with patients. Most time was allocated to documentation and conversation with colleagues and nursing staff. Physicians performed parallel simultaneous activities for 17-20% of their work time. Communication with patients, documentation, and conversation with colleagues and nursing staff were the most frequently observed simultaneous activities. Applying logit-linear analyses, specific primary activities increase the probability of particular simultaneous activities.

CONCLUSION

Patient-related working time in hospitals is limited. The potential detrimental effects of frequently observed simultaneous activities on performance outcomes need further consideration.

Intern to attending: assessing stress among physicians

PURPOSE

Organizations have raised concerns regarding stress in the medical work environment and effects on health care worker performance. This study's objective was to assess workplace stress among interns, residents, and attending physicians using Ecological Momentary Assessment technology, the gold-standard method for real-time measurement of psychological characteristics.

METHOD

The authors deployed handheld computers with customized software to 185 physicians on the medicine and pediatric wards of four major teaching hospitals. The physicians contemporaneously recorded multiple dimensions of physician work (e.g., type of call day), emotional stress (e.g., worry, stress, fatigue), and perceived workload (e.g., patient volume). The authors performed descriptive statistics and t test and linear regression analyses.

RESULTS

Participants completed 5,673 prompts during an 18-month period from 2004 to 2005. Parameters associated with higher emotional stress in linear regression models included male gender (t = -2.5, P = .01), total patient load (t = 4.2, P < .001), and sleep quality (t = -2.8, P = .006). Stress levels reported by attendings (t = -3.3, P = .001) were lower than levels reported by residents (t = -2.6, P = .009), and emotional stress levels of attendings and residents were both lower compared with interns.

CONCLUSIONS

On inpatient wards, after recent resident duty hours changes, physician trainees continue to show wide-ranging evidence of workplace stress and poor sleep quality. This is among the first studies of medical workplace stress in real time. These results can help residency programs target education in stress and sleep and readdress workload distribution by training level. Further research is needed to clarify behavioral factors underlying variability in housestaff stress responses.

The impact of duty hours on resident self reports of errors

BACKGROUND

Resident duty hour limitations aim, in part, to reduce medical errors. Residents' perceptions of the impact of duty hours on errors are unknown.

OBJECTIVE

To determine residents' self-reported contributing factors, frequency, and impact of hours worked on suboptimal care practices and medical errors.

DESIGN

Cross-sectional survey.

SUBJECTS

164 Internal Medicine Residents at the University of California, San Francisco.

MEASUREMENTS AND RESULTS

Residents were asked to report the frequency and contributing factors of suboptimal care practices and medical errors, and how duty hours impacted these practices and aspects of resident work-life. One hundred twenty-five residents (76%) responded. The most common suboptimal care practices were working while impaired by fatigue and forgetting to transmit information during sign-out. In multivariable models, residents who felt overwhelmed with work (p = 0.02) and who reported spending >50% of their time in nonphysician tasks (p = 0.002) were more likely to report suboptimal care practices. Residents reported work-stress (a composite of fatigue, excessive workload, distractions, stress, and inadequate time) as the most frequent contributing factor to medical errors. In multivariable models, only engaging in suboptimal practices was associated with self-report of higher risk for medical errors (p < 0.001); working more than 80 hours per week was not associated with suboptimal care or errors.

CONCLUSION

Our findings suggest that administrative load and work stressors are more closely associated with resident reports of medical errors than the number of hours work. Efforts to reduce resident duty hours may also need to address the nature of residents' work to reduce errors.

The educational impact of ACGME limits on resident and fellow duty hours: a pre-post survey study

PURPOSE

To assess the educational impact of Accreditation Council for Graduate Medical Education resident work-hour limits implemented in July 2003.

METHOD

All trainees in all 76 accredited programs at two large teaching hospitals were surveyed between May and June 2003 (before work-hour reductions) and then between May and June 2004 (after work-hour reductions) about hours, education, and fatigue. Based on changes in weekly duty hours, 13 programs experiencing substantial reduction in hours were classified into a reduced-hours group. Differences in assessments of educational endpoints before and after policy implementation by trainees in the reduced-hours group were compared with those in other programs to control for potential temporal trends, using two-way ANOVA with interaction.

RESULTS

The number of respondents was 1,770 (60% response rate). The reduced-hours group reported a significant decrease in time spent directly caring for patients (from 48.5 to 42.3 mean h/wk, P = 0.03), but the volume of important clinical experiences, including procedures, was preserved, as was the sense of clinical preparedness. On 22 questions related to educational quality and adequacy, only three differences in differences were significant, with the reduced-hours group reporting a relative increase in opportunities for research, decrease in quality of faculty teaching, and decrease in educational satisfaction. The percentage of trainees reporting frequent negative effects of fatigue dropped more in the reduced-hours programs than in the other programs (P < 0.05).

CONCLUSION

This study shows that it may be possible to reduce residents' hours--and the perceived adverse impact of fatigue--while generally preserving the self-assessed quality, quantity, and outcomes of graduate medical education.

Relationship between resident workload and self-perceived learning on inpatient medicine wards: a longitudinal study

BACKGROUND

Despite recent residency workload and hour limitations, little research on the relationship between workload and learning has been done. We sought to define residents' perceptions of the optimal patient workload for learning, and to determine how certain variables contribute to those perceptions. Our hypothesis was that the relationship between perceived workload and learning has a maximum point (forming a parabolic curve): that either too many or too few patients results in sub-optimal learning.

METHODS

Residents on inpatient services at two academic teaching hospitals reported their team and individual patient censuses, and rated their perception of their learning; the patient acuity; case variety; and how challenged they felt. To estimate maximum learning scores, linear regression models with quadratic terms were fit on learning score.

RESULTS

Resident self-perceived learning correlated with higher acuity and greater heterogeneity of case variety. The equation of census versus learning score, adjusted for perception of acuity and case mix scores, showed a parabolic curve in some cases but not in others.

CONCLUSION

These data suggest that perceived resident workload is complex, and impacted by additional variables including patient acuity and heterogeneity of case variety. Parabolic curves exist for interns with regard to overall census and for senior residents with regard to new admissions on long call days.

Impact of reduced duty hours on residents' educational satisfaction at the University of California, San Francisco

PURPOSE

To assess the impact of the Accreditation Council for Graduate Medical Education duty-hour limitations on residents' educational satisfaction.

METHOD

In 2003, the authors surveyed 164 internal medicine residents at three clinical training sites affiliated with the University of California, San Francisco, after system changes were introduced to reduce duty hours. On a questionnaire that used various rating scales, residents reported the value of educational activities, frequency of administrative tasks interfering with education, and educational satisfaction after duty hours were reduced. The authors compared univariate statistics and developed multivariable models to discern the relationship between hours worked and educational outcomes.

RESULTS

In all, 125 residents (76%) responded. Residents rated the educational activities, morning report, and teaching others most highly. Answering pages and tasks related to scheduling were the most frequent barriers to educational activities. Residents reported that time spent in administrative activities did not change after duty-hour restrictions, and 68% said that decreased duty hours had no impact or a negative impact on education. In multivariable models, postgraduate year (PGY)-1 residents (p = .004), residents who reported feeling overwhelmed at work (p < .0001), and residents who reported working more than 80 hours per week (p < .05) had lower work satisfaction. However, only PGY-1 residents (p < .05) and those who felt overwhelmed with work (p = .01) were less satisfied with their education.

CONCLUSIONS

In this residency program, duty-hour reduction did not improve educational satisfaction. Educational satisfaction may be more a function of workload than hours worked; therefore, systematic changes to residents' work-life may be necessary to improve educational satisfaction.

Impact of Emergency Department Volume on Registered Nurse Time at the Bedside

STUDY OBJECTIVE

We determine how emergency department (ED) registered nurses (RNs) allocate their time between various tasks and describe how RN task distribution changes as a function of various measures of ED patient volume and patient acuity.

METHODS

This is a 3-year direct observational study using a convenience sample of 63 8-hour nurse shifts. Four RN task categories were defined: (1) direct patient care, (2) indirect patient care, (3) non-RN care, and (4) personal time. Two measures of nurse workload were used, the patient-to-nurse ratio and the ED acuity index (ED acuity index=(Sigma reverse order triage scores/half hour)/total number of nurses staffing). Trained observers classified RN activity at 1-minute intervals during 8-hour shifts daily for 7 nonconsecutive 24-hour periods. RN staffing data, ED patient census, and patient triage scores were collected every half hour. Summary statistics, correlation tables, and regression analysis were used to establish relationships between RN task allocation, patients per nurse, and the ED acuity index.

RESULTS

For the 63 nursing shifts studied, on average RNs spent 25.6% of their time performing direct patient care, 48.4% on indirect patient care, 6.8% on non-RN care, and 19.1% on personal time. Regardless of the number of patients per RN, approximately twice as much time is spent on indirect patient care as direct patient care. The correlation between the ED acuity index and the patient-to-nurse ratio was 0.98.

CONCLUSION

Regardless of workload, RNs spend the majority of their time performing indirect patient care. RNs spend little time performing tasks that could be performed by ancillary staff. The patient-to-nurse ratio performs just as well as a more complicated acuity index to measure the workload of RNs within an ED.

Differing mental health practice among general practitioners, private psychiatrists and public psychiatrists

BACKGROUND

Providing care for mental health problems concerns General Practitioners (GPs), Private Psychiatrists (PrPs) and Public Psychiatrists (PuPs). As patient distribution and patterns of practice among these professionals are not well known, a survey was planned prior to a re-organisation of mental health services in an area close to Paris

METHODS

All GPs (n = 492), PrPs (n = 82) and PuPs (n = 78) in the South-Yvelines area in France were informed of the implementation of a local mental health program. Practitioners interested in taking part were invited to include prospectively all patients with mental health problem they saw over an 8-day period and to complete a 6-month retrospective questionnaire on their mental health practice. 180 GPs (36.6%), 45 PrPs (54.9%) and 63 PuPs (84.0%) responded.

RESULTS

GPs and PrPs were very similar but very different from PuPs for the proportion of patients with anxious or depressive disorders (70% v. 65% v. 38%, p < .001), psychotic disorders (5% v. 7% v. 30%, p < .001), previous psychiatric hospitalization (22% v. 26 v. 61%, p < .001) and receiving disability allowance (16% v. 18% v. 52%, p < .001). GPs had fewer patients with long-standing psychiatric disorders than PrPs and PuPs (52%, 64% v. 63%, p < .001). Time-lapse between consultations was longest for GPs, intermediate for PuPs and shortest for PrPs (36 days v. 26 v. 18, p < .001). Access to care had been delayed longer for Psychiatrists (PrPs, PuPs) than for GPs (61% v. 53% v. 25%, p < .001). GPs and PuPs frequently felt a need for collaboration for their patients, PrPs rarely (42% v. 61%. v. 10%, p < .001). Satisfaction with mental health practice was low for all categories of physicians (42.6% encountered difficulties hospitalizing patients and 61.4% had patients they would prefer not to cater for). GPs more often reported unsatisfactory relationships with mental health professionals than did PrPs and PuPs (54% v. 15% v. 8%, p < .001).

CONCLUSION

GP patients with mental health problems are very similar to patients of private psychiatrists; there is a lack of the collaboration felt to be necessary, because of psychiatrists' workload, and because GPs have specific needs in this respect. The "Yvelines-Sud Mental Health Network" has been created to enhance collaboration.

What do surgery residents do on their call nights?

BACKGROUND

Surgical resident education is entering a critical era of achieving core competencies despite work hour restrictions. An assessment of on-call activity is needed to maximize educational merit.

METHODS

A time-motion study of resident on-call activity was performed at a university medical center and an urban affiliate hospital. Residents were followed by "shadow" residents who concurrently recorded resident activity.

RESULTS

Activities of daily living and patient evaluation comprised the majority of on-call activity. Residents slept a median of 200 minutes per night. Cross-coverage activities accounted for 41% of pages and 19% of patient evaluation. Direct patient contact comprised only 7% of call night duties. Communication activity occupied 15% of total minutes, and a mean of 16 pages were received nightly. Significant differences in activities existed between resident levels and hospitals.

CONCLUSIONS

Call activity consists primarily of activities of daily living, patient evaluation, and communication. Sleep accounts for nearly one third of all on-call activity. These data may be useful in improving both patient care and resident call experience.

The impact of resident duty hour reform in a medicine core clerkship

PROBLEM STATEMENT

Residency programs have changed to comply with resident duty hour regulations. This study's purpose was to determine if there are differences in medicine clerkship students' activities, associations, and perceptions of educational value before and after duty hour reform.

METHOD

Medicine clerkship students, both before (n = 36) and after (n = 33) duty hour reform, wore random reminder pagers for one week and completed time allocation surveys with each signal. Event proportions were calculated and analysis of variance assessed group differences.

RESULTS

A total of 804 and 912 surveys were completed before and after reform, respectively. No differences existed in proportion of time for direct patient care (.13 versus.14, p =.35), indirect patient care (.35 versus.32, p =.21), and education (.38 versus.37, p =.69) activities, students' associations, educational value, and time in the hospital before and after reform.

CONCLUSIONS

Residency program changes had minimal impact on medicine clerkship students.

Understanding residents' work: moving beyond counting hours to assessing educational value

PURPOSE

To begin to understand how residents' work affects their own educations and the hospitals in which most of their training takes place, the authors undertook a systematic review of the literature analyzing residents' activities. This review sought to analyze resident physicians' activities to assess the educational value of residents' work.

METHOD

The published literature was searched in 2001 using the Medline and Science Citation Index databases, and the unpublished literature was searched using bibliographies and key informants. One hundred six studies were rated for methodological rigor using the Cochrane Collaboration protocol, as modified by Bland et al. for nonclinical trials. Only those studies undertaken following the Bell Commission's report in 1987 and whose methodological rigor score fell at or above the median for all studies rated were included in the data synthesis. Results data from 16 studies that included over 1,000 residents in six different specialties, were combined under the definitions of types of residents' activities: marginal, patient care, teaching and learning, and other.

RESULTS

This preliminary analysis found that residents devoted approximately 36% of their effort to direct patient care necessary to achieve specialty-specific learning objectives, 15% to the residency program's organized teaching activities, and potentially as much as 35% to delivering patient care of marginal or no educational value. An additional 16% of residents' waking time on duty was spent in other, unspecified activities.

CONCLUSION

It is possible and potentially valuable to consider not only the number of hours worked by residents, but the educational content of their work when considering residency work and hour reforms

Implementing a disease management intervention for depression in primary care: a random work sampling study

We describe the daily work activities of 13 Depression Clinical Specialists (DCSs) at 7 national sites who served as care managers in an effective multisite randomized trial of a disease management model for depression in primary care. DCSs carried portable random-reminder beepers for a total of 147 consecutive workdays and recorded 4,030 work activities. Patient care activity comprised the largest percentage of the workday, 49.4% (95% confidence interval [CI], 42.0 to 56.7%), followed by research-related activity, 18.3 % (95% CI, 14.7 to 21.9%), administrative work, 17.9% (95% CI, 12.2 to 23.7%), personal time, 9.4% (95% CI, 5.4 to 13.4%), and time in transit, 5.1% (95% CI, 2.8 to 7.4%). The DCSs delivered 19.2% (95% CI, 14.4 to 24.1%) of direct patient care by telephone. The DCSs spent a significant portion of the day alone 48.7% (95% CI, 43.3 to 54.1%), followed by time spent with patients, 37.5% (95% CI, 31.6 to 43.3%). Less than 10% (7.8%) (95% CI, 5.1 to 10.6%) of their time was spent with local study staff. Less than 4% of their time was spent with other health care providers. Our results demonstrate that the DCSs' time was primarily devoted to clinical care, a significant portion of which was delivered by telephone. They functioned independently, making efficient use of the limited amount of time that they interacted with other health care providers. This information will be helpful to those who may wish to implement this disease management strategy.

First-postgraduate-year resident clinical time use on three specialty rotations

OBJECTIVE

To compare in-hospital time uses by first-postgraduate-year (PGY1) residents during rotations in emergency medicine (EM), internal medicine (IM), and surgery (S). This article reports the clinical components of residency time use.

METHODS

A cross-sectional, observational study of the clinical activities of EM PGY1 residents was performed while the residents were on duty during the three specialty rotations. The activities were recorded by an observer using a log with predetermined categories for clinical activities. A time-blocked, convenience sample of resident shifts was observed for each service rotation. The sample was proportional to the total number of hours for which a PGY1 resident was expected to be in the hospital during a rotation on that service. No attempt was made to sample the same resident at all time periods or on all rotations. Proportions were compared by chi2; alpha = 0.0001.

RESULTS

Twelve PGY1 residents were observed for a total of 166 hours on S, 156 hours on IM, and 120 hours on EM. These hourly amounts were representative of a typical two-week span of service on each rotation for the residents. On average, the residents spent 57% of their time on clinical or service-oriented activities. During EM and IM rotations, the residents spent most of their time performing clinical information gathering and engaging in case management and data synthesis (52% of total clinical effort). Within this category, residents on EM were more involved with case discussion and review of ancillary test results than on IM (34% vs 20% of time in this category). Conversely, proportionately less time in this category was devoted to documentation on the EM vs IM rotation (56% vs 80%; p < 0.0001). The greatest opportunity to perform procedures was on the S rotation (31% of total clinical time vs 6% for other specialties; p < 0.0001).

CONCLUSION

Awareness of the clinical activities performed on PGY1 rotations can help residency directors anticipate educational needs to balance their residents' experience. Since 29% and 42% of total clinical time on PGY1 EM and IM rotations, respectively, is focused on documentation, efforts to enhance charting skills and efficiency are warranted. Also, efforts to enhance PGY1 procedural experience outside of the S rotation appear warranted.