Time-motion studies of internal medicine residents' duty hours: a systematic review and meta-analysis

Characterizing nursing time with patients using computer vision

BACKGROUND

Compared to other providers, nurses spend more time with patients, but the exact quantity and nature of those interactions remain largely unknown. The purpose of this study was to characterize the interactions of nurses at the bedside using continuous surveillance over a year long period.

METHODS

Nurses' time and activity at the bedside were characterized using a device that integrates the use of obfuscated computer vision in combination with a Bluetooth beacon on the nurses' identification badge to track nurses' activities at the bedside. The surveillance device (AUGi) was installed over 37 patient beds in two medical/surgical units in a major urban hospital. Forty-nine nurse users were tracked using the beacon. Data were collected 4/15/19-3/15/20. Statistics were performed to describe nurses' time and activity at the bedside.

RESULTS

A total of n = 408,588 interactions were analyzed over 670 shifts, with >1.5 times more interactions during day shifts (n = 247,273) compared to night shifts (n = 161,315); the mean interaction time was 3.34 s longer during nights than days (p < 0.0001). Each nurse had an average of 7.86 (standard deviation [SD] = 10.13) interactions per bed each shift and a mean total interaction time per bed of 9.39 min (SD = 14.16). On average, nurses covered 7.43 beds (SD = 4.03) per shift (day: mean = 7.80 beds/nurse/shift, SD = 3.87; night: mean = 7.07/nurse/shift, SD = 4.17). The mean time per hourly rounding (HR) was 69.5 s (SD = 98.07) and 50.1 s (SD = 56.58) for bedside shift report.

DISCUSSION

As far as we are aware, this is the first study to provide continuous surveillance of nurse activities at the bedside over a year long period, 24 h/day, 7 days/week. We detected that nurses spend less than 1 min giving report at the bedside, and this is only completed 20.7% of the time. Additionally, hourly rounding was completed only 52.9% of the time and nurses spent only 9 min total with each patient per shift. Further study is needed to detect whether there is an optimal timing or duration of interactions to improve patient outcomes.

CLINICAL RELEVANCE

Nursing time with the patient has been shown to improve patient outcomes but precise information about how much time nurses spend with patients has been heretofore unknown. By understanding minute-by-minute activities at the bedside over a full year, we provide a full picture of nursing activity; this can be used in the future to determine how these activities affect patient outcomes.

Learning Theories Versus Practice: How Do Internal Medicine Residents Study for Licensing Examinations?

OBJECTIVE

 The ability to recall relevant medical knowledge within clinical contexts is a critical aspect of effective and efficient patient diagnosis and management. The ever-growing and changing body of medical literature requires learners to develop effective life-long learning techniques. Learners can more successfully build their fund of knowledge and ability to retrieve it by using evidence-based learning strategies. Our objective was to evaluate the study habits of internal medicine (IM) residents at an academic institution to understand if they apply key learning strategies for the American Board of Internal Medicine (ABIM) exam preparation. We also briefly review various learning strategies that can be applied to IM residency curricula.

METHODS

A web-based survey consisting of 16 multiple-response questions on study habits was filled out by the IM residents in 2019 at Tufts Medical Center.

RESULTS

Of the 75 residents invited to participate in the study, 69 responded (response rate = 92%). Of the responders, n=25 (36.2%) were post-graduate year (PGY)-1, n=20 (29.0%) were PGY-2, and n=24 (34.8%) were PGY-3 residents. More than half the residents (n=40, 58%) had Step 2 Clinical Knowledge (CK) scores > 250. Residents self-reported applying spaced learning (67%), interleaving (64%), retrieval (64%), and elaboration practices (46%) for exam preparation. There was a significant association between the Step 2 CK score and elaboration (p=0.017) technique but not with spaced learning, interleaving, or retrieval. The majority of residents felt not at all prepared (n=42, 60.9%) for the ABIM exam.

CONCLUSIONS

Despite two years of clinical training, 33% of the third-year residents felt inadequately prepared for the board certification exam. Incorporating evidence-based learning strategies into their daily curriculum may help them better prepare for the ABIM exam.

Association of Mobile Workstations and Rounding-in-Flow with Resident Efficiency: A Controlled Study at an Academic Internal Medicine Department

BACKGROUND

Residents commonly use a batched workflow to round on hospitalized patients, creating redundancy and decreasing efficiency.

OBJECTIVE

To improve resident efficiency through a novel workflow using mobile laptops and modified rounding-in-flow.

DESIGN, SETTING, PARTICIPANTS

A controlled experimental study conducted at an academic medical center for 3 months. One internal medicine team served as the intervention group, and two other teams served as a control group; 34 interns and 20 senior residents participated.

INTERVENTION

Residents in the intervention group were provided a novel workflow and a mobile laptop to allow them to round "in-flow." Control group residents rounded as usual (batched workflow without laptops).

MAIN MEASURES

Fourteen interns were monitored for a time-motion study. Time-stamped electronic medical record (EMR) data were used to assess percentage of progress notes and orders placed during rounds (9 a.m.-12:30 p.m.) and percentage of discharge summaries signed within 24 h of discharge. A post-intervention survey measured perceived efficiency.

RESULTS

A time-motion study showed non-significant differences between time in the intervention group and that in the control group: communication time with patients (128 min vs 105 min, p = 0.37) and computer time (289 min vs 306 min, p = 0.71). EMR data for 664 visits in the control group and 374 in the intervention group showed that rounding-in-flow was associated with an odds ratio (OR) of 1.5 for placing progress notes during rounds (95% CI: 1.2-1.7, p < 0.001), an OR of 1.1 for placing non-discharge orders during rounds (95% CI: 1.0-1.2, p = 0.01), and an OR of 3.9 for signing discharge summaries within 24 h of discharge (95% CI: 2.3-7.2, p < 0.001). Post-intervention survey, completed by 23 of 34 interns, showed that interns in the intervention group perceived that orders were completed during rounds more often than the control group (OR 7.8; 95% CI: 1.3-60.1, p = 0.03).

CONCLUSIONS

Using mobile laptops with modified rounding-in-flow was associated with earlier completion of residents' work, suggesting improved efficiency.

Importance of communication in medical practice and medical education: An emphasis on empathy and attitudes and their possible influences

BACKGROUND

Healthcare professionals need to be prepared to promote healthy lifestyles and care for patients. By focusing on what students should be able to perform one day as clinicians, we can bridge the gap between mere theoretical knowledge and its practical application. Gender aspects in clinical medicine also have to be considered when speaking of personalized medicine and learning curricula.

AIM

To determine sets of intellectual, personal, social, and emotional abilities that comprise core qualifications in medicine for performing well in anamnesis-taking, in order to identify training needs.

METHODS

An analysis of training clinicians’ conceptions with respect to optimal medical history taking was performed. The chosen study design also aimed to assess gender effects. Structured interviews with supervising clinicians were carried out in a descriptive study at the Medical University of Vienna. Results were analyzed by conducting a qualitative computer-assisted content analysis of the interviews. Inductive category formation was applied. The main questions posed to the supervisors dealt with (1) Observed competencies of students in medical history taking; and (2) The supervisor’s own conceptions of "ideal medical history taking".

RESULTS

A total of 33 training clinicians (n = 33), engaged in supervising medical students according to the MedUni Vienna’s curriculum standards, agreed to be enrolled in the study and met inclusion criteria. The qualitative content analysis revealed the following themes relevant to taking an anamnesis: (1) Knowledge; (2) Soft skills (relationship-building abilities, trust, and attitude); (3) Methodical skills (structuring, precision, and completeness of information gathering); and (4) Environmental/contextual factors (language barrier, time pressure, interruptions). Overall, health care professionals consider empathy and attitude as critical features concerning the quality of medical history taking. When looking at physicians’ theoretical conceptions, more general practitioners and psychiatrists mentioned attitude and empathy in the context of "ideal medical history taking", with a higher percentage of females. With respect to observations of students’ history taking, a positive impact from attitude and empathy was mainly described by male health care professionals, whereas no predominance of specialty was found. Representatives of general medicine and internal medicine, when observing medical students, more often emphasized a negative impact on history taking when students lacked attitude or showed non-empathetic behavior; no gender-specific difference was detected for this finding.

CONCLUSION

The analysis reveals that for clinicians engaged in medical student education, only a combination of skills, including adequate knowledge and methodical implementations, is supposed to guarantee acceptable performance. This study’s findings support the importance of concepts like relationship building, attitude, and empathy. However, there may be contextual factors in play as well, and transference of theoretical concepts into the clinical setting might prove challenging.

Physicians' working time restriction and its impact on patient safety: an integrative review

BACKGROUND

Although shift work is a part of the physicians' routine, there is controversy on the length of shifts and adequate rest for safe professional practice. If on the one hand long working hours might have negative impact on patient safety by interfering with the psychological and physical functioning of physicians, on the other shorter working hours might impair the safety of patients due to interference with the continuity of care.

OBJECTIVE

To analyze the impact of restrictions to physicians' working hours on patient safety.

METHOD

Integrative literature review in which we surveyed studies on restriction to physicians' working time and patient safety included in databases National Library of Medicine (PubMed) and Scientific Electronic Library Online (SciELO) until May 2018. Thirty-five studies which met the inclusion criteria were included.

RESULTS

Patient safety outcomes analyzed in the included studies were mortality, adverse events, continuity of care, in-hospital complications, readmission rate and length of stay at hospital. Restriction to working time was associated with variable impact on patient safety indicators, but often did not modify their performance.

CONCLUSION

Restrictions to physicians' working time did not always improved patient safety indicators. Focusing on interventions which only seek to limit the workload of physicians might be insufficient to bring consistent improvement to patient care.

Quantifying the Impact of Trainee Providers on Outpatient Clinic Workflow using Secondary EHR Data

Providers today face productivity challenges including increased patient loads, increased clerical burdens from new government regulations and workflow impacts of electronic health records (EHR). Given these factors, methods to study and improve clinical workflow continue to grow in importance. Despite the ubiquitous presence of trainees in academic outpatient clinics, little is known about the impact of trainees on academic workflow. The purpose of this study is to demonstrate that secondary EHR data can be used to quantify that impact, with potentially important results for clinic efficiency and provider reimbursement models. Key findings from this study are that (1) Secondary EHR data can be used to reflect in clinic trainee activity, (2) presence of trainees, particularly in high-volume clinic sessions, is associated with longer session lengths, and (3) The timing of trainee appointments within clinic sessions impacts the session length.

Time is of the essence: an observational time-motion study of internal medicine residents while they are on duty

BACKGROUND

The effects of changes to resident physician duty hours need to be measureable. This time-motion study was done to record internal medicine residents' workflow while on duty and to determine the feasibility of capturing detailed data using a mobile electronic tool.

METHODS

Junior and senior residents were shadowed by a single observer during six-hour blocks of time, covering all seven days. Activities were recorded in real-time. Eighty-nine activities grouped into nine categories were determined a priori.

RESULTS

A total of 17,714 events were recorded, encompassing 516 hours of observation. Time was apportioned in the following categories: Direct Patient Care (22%), Communication (19%), Personal tasks (15%), Documentation (14%), Education (13%), Indirect care (11%), Transit (6%), Administration (0.6%), and Non-physician tasks (0.4%). Nineteen percent of the education time was spent in self-directed learning activities. Only 9% of the total on duty time was spent in the presence of patients. Sixty-five percent of communication time was devoted to information transfer. A total of 968 interruptions were recorded which took on average 93.5 seconds each to service.

CONCLUSION

Detailed recording of residents' workflow is feasible and can now lead to the measurement of the effects of future changes to residency training. Education activities accounted for 13% of on-duty time.

Using telephony data to facilitate discovery of clinical workflows

BACKGROUND

Discovery of clinical workflows to target for redesign using methods such as Lean and Six Sigma is difficult. VoIP telephone call pattern analysis may complement direct observation and EMR-based tools in understanding clinical workflows at the enterprise level by allowing visualization of institutional telecommunications activity.

OBJECTIVE

To build an analytic framework mapping repetitive and high-volume telephone call patterns in a large medical center to their associated clinical units using an enterprise unified communications server log file and to support visualization of specific call patterns using graphical networks.

METHODS

Consecutive call detail records from the medical center's unified communications server were parsed to cross-correlate telephone call patterns and map associated phone numbers to a cost center dictionary. Hashed data structures were built to allow construction of edge and node files representing high volume call patterns for display with an open source graph network tool.

RESULTS

Summary statistics for an analysis of exactly one week's call detail records at a large academic medical center showed that 912,386 calls were placed with a total duration of 23,186 hours. Approximately half of all calling called number pairs had an average call duration under 60 seconds and of these the average call duration was 27 seconds.

CONCLUSIONS

Cross-correlation of phone calls identified by clinical cost center can be used to generate graphical displays of clinical enterprise communications. Many calls are short. The compact data transfers within short calls may serve as automation or re-design targets. The large absolute amount of time medical center employees were engaged in VoIP telecommunications suggests that analysis of telephone call patterns may offer additional insights into core clinical workflows.