Hospitalist time usage and cyclicality: opportunities to improve efficiency

The Inpatient Experience of Emerging Adults: Transitioning From Pediatric to Adult Care

The pediatric-to-adult care transition has been correlated with worse outcomes, including increased mortality. Emerging adults transitioning from child-specific healthcare facilities to adult hospitals encounter marked differences in environment, culture, and processes of care. Accordingly, emerging adults may experience care differently than other hospitalized adults. We performed a retrospective cohort study of patients admitted to a large urban safety net hospital and compared all domains of patient experience between patients in 3 cohorts: ages 18 to 21, 22 to 25, and 26 years and older. We found that patient experience for emerging adults aged 18 to 21, and, to a lesser extent, aged 22 to 25, was significantly and substantially worse as compared to adults aged 26 and older. The domains of worsened experience were widespread and profound, with a 38-percentile difference in overall experience between emerging adults and established adults. While emerging adults experienced care worse in nearly all domains measured, the greatest differences were found in those pertinent to relationships between patients and care providers, suggesting a substantial deficit in our understanding of the preferences and values of emerging adults.

Implementation of a triage nurse role and the effect on hospitalist workload

OBJECTIVES

Hospital medicine groups vary staffing models to match available workforce with expected patient volumes and acuity. Larger groups often assign a single hospitalist to triage pager duty which can be burdensome due to frequent interruptions and multitasking. We introduced a new role, the Triage nurse, to hold the triage pager and distribute patients. We sought to determine the effect of this Triage Nurse on the perceived workload of hospitalists and frequency of pages.

METHODS

We partnered with our patient throughput department to implement the Triage Nurse role who took the responsibility of tracking and distributing admissions among three admitting physicians along with coordinating report. We used the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) to measure perceived workload and accessed pager logs of admitters for 3 months before and after implementation.

RESULTS

Overall, 50 of an expected 67 NASA-TLX surveys (74.6%) were returned in the pre-intervention period and 64 of 92 (69.6%) were returned in the post-intervention period. We found a statistically significant reduction in the domains of physical demand, temporal demand, effort and frustration from pre- to post-intervention periods (p < 0.01). There was also a significant decrease in the performance domain (p = 0.01) with a lower number indicative of better perceived performance. There was a significant reduction in the mean number of pages received by admitting hospitalists over their 9-h shifts (81.3 + 17.3 vs 52.4 + 7.3; p < 0.01).

CONCLUSION

The implementation of the Triage Nurse role was associated with a significant decrease in the perceived workload of admitting hospitalists. Our findings are important because workload and interruptions can contribute to errors and burnout. Future studies should test interventions to improve hospitalist workload and evaluate their effect on patient outcomes and physician wellness.

Impact on Participants of Family Connect, a Novel Program Linking COVID-19 Inpatients' Families With the Frontline Providers

Purpose

With clinical volumes decreased, radiologists volunteered to participate virtually in daily clinical rounds and provide communication between frontline physicians and patients with coronavirus disease 2019 (COVID-19) and their families affected by restrictive hospital visitation policies. The purpose of this survey-based assessment was to demonstrate the beneficial effects of radiologist engagement during this pandemic and potentially in future crises if needed.

Methods

After the program’s completion, a survey consisting of 13 multiple-choice and open-ended questions was distributed to the 69 radiologists who volunteered for a minimum of 7 days. The survey focused on how the experience would change future practice, the nature of interaction with medical students, and the motivation for volunteering. The electronic medical record system identified the patients who tested positive for or were suspected of having COVID-19 and the number of notes documenting family communication.

Results

In all, 69 radiologists signed or cosigned 7,027 notes. Of the 69 radiologists, 60 (87.0%) responded to the survey. All found the experience increased their understanding of COVID-19 and its effect on the health care system. Overall, 59.6% agreed that participation would result in future change in communication with patients and their families. Nearly all (98.1%) who worked with medical students agreed that their experience with medical students was rewarding. A majority (82.7%) chose to participate as a way to provide service to the patient population.

Conclusion

This program provided support to frontline inpatient teams while also positively affecting the radiologist participants. If a similar situation arises in the future, this communication tool could be redeployed, especially with the collaboration of medical students.

Observing and Identifying Hospitalist Best Communication Practices in Patient Interactions

This study identifies actual hospitalist best communication practices that optimize patient interactions in a busy hospital context. We observed and rated 36 hospitalists and 206 patient encounters using the Kalamazoo Essential Elements of Communication Checklist-Adapted (KEECC-A). We collected descriptive statistics of checklist scores and thematically analyzed fieldnotes to identify communication patterns. Results show hospitalists score highest and most frequently use three of seven KEECC-A dimensions: builds a relationship, shares information, and gathers information. We first identify exemplar behaviors and then provide statistical comparisons by professional and hospital tenure, gender, and day of rounding observed for these three dimensions. Male hospitalists scored higher than females for shares information and significant differences were found for gender between cross-sex patient-hospitalist interactions. Hospitalists early in their professional and hospital tenure received significantly lower ratings than mid-to-late career hospitalists in the three KEECC dimensions. Hospitalists observed on the first day of rounding received significantly higher ratings than those observed on a middle or last day. We offer interpretations to explain study findings and suggest interventions to help hospitalists with less-than-desirable communication skills.

Incorporating Continuity in a 7-On 7-Off Hospitalist Model and the Correlation With Patient Handoffs and Length of Stay

Little research in hospital medicine examines the effects of hospitalist continuity on patient outcomes. This study implemented a novel staffing model with approximately half of rounding teams starting their 7-day workweek on Monday and the others on Friday. Teams admitted their own patients on their first 4 days with additional nighttime admissions handed off to those teams. No admissions were given to teams on their last 3 days. Length of stay was significantly reduced from 6.34 days in 2015 to 5.7 days in 2016 (P < .002) with a significant decrease in handoffs. There was an increase in odds ratio of death (1.37, SE = .128) with each additional hospitalist involved in a patient's care while adjusting for year and number of patient diagnoses (P < .001). There was no statistical difference in charges, 30-day readmissions, or mortality between years.

The impact of electronic health record systems on clinical documentation times: A systematic review

BACKGROUND

Effective management of hospital staff time is crucial to quality patient care. Recent years have seen widespread implementation of electronic health record (EHR) systems but the effect of this on documentation time is unknown. This review compares time spent on documentation tasks by hospital staff (physicians, nurses and interns) before and after EHR implementation.

METHODS

A systematic search identified 8153 potentially relevant citations. Studies examining proportion of total workload spent on documentation with ≥40 h of staff observation time were included. Meta-analysis was performed for physicians, nurses and interns comparing pre- and post-EHR results. Studies were weighted by person-hours observation time.

RESULTS

Twenty-eight studies met selection criteria. Seventeen were pre-EHR, nine post-EHR and two examined both periods. With implementation of EHR, physicians' documentation time increased from 16% (95% confidence interval (CI) 11-22%) to 28% (95% CI 19-37%), nurses from 9% (95% CI 6-12%) to 23% (95% CI 15-32%) and interns from 20% (95% CI 7-32%) to 26% (95% CI 10-42%).

CONCLUSIONS

There is a lack of long-term follow-up on the effects of EHR implementation. Initial adjustment to EHR appears to increase documentation time but there is some evidence that as staff become more familiar with the system, it may ultimately improve work flow.

Assessing the precision of a time-sampling-based study among GPs: balancing sample size and measurement frequency

BACKGROUND

Our research is based on a technique for time sampling, an innovative method for measuring the working hours of Dutch general practitioners (GPs), which was deployed in an earlier study. In this study, 1051 GPs were questioned about their activities in real time by sending them one SMS text message every 3 h during 1 week. The required sample size for this study is important for health workforce planners to know if they want to apply this method to target groups who are hard to reach or if fewer resources are available. In this time-sampling method, however, standard power analyses is not sufficient for calculating the required sample size as this accounts only for sample fluctuation and not for the fluctuation of measurements taken from every participant. We investigated the impact of the number of participants and frequency of measurements per participant upon the confidence intervals (CIs) for the hours worked per week.

METHODS

Statistical analyses of the time-use data we obtained from GPs were performed. Ninety-five percent CIs were calculated, using equations and simulation techniques, for various different numbers of GPs included in the dataset and for various frequencies of measurements per participant.

RESULTS

Our results showed that the one-tailed CI, including sample and measurement fluctuation, decreased from 21 until 3 h between one and 50 GPs. As a result of the formulas to calculate CIs, the increase of the precision continued and was lower with the same additional number of GPs. Likewise, the analyses showed how the number of participants required decreased if more measurements per participant were taken. For example, one measurement per 3-h time slot during the week requires 300 GPs to achieve a CI of 1 h, while one measurement per hour requires 100 GPs to obtain the same result.

CONCLUSIONS

The sample size needed for time-use research based on a time-sampling technique depends on the design and aim of the study. In this paper, we showed how the precision of the measurement of hours worked each week by GPs strongly varied according to the number of GPs included and the frequency of measurements per GP during the week measured. The best balance between both dimensions will depend upon different circumstances, such as the target group and the budget available.

Delivery of Community-Based Palliative Care: Findings from a Time and Motion Study

BACKGROUND

Use of palliative care has increased substantially as the population ages and as evidence for its benefits grows. However, there is limited information regarding which care activities are necessary for delivering high-quality, interdisciplinary, community-based palliative care.

OBJECTIVES

This study aims to identify and measure the discrete clinical and administrative activities completed by a multidisciplinary team in a hospice provider-led model for providing community-based palliative care.

STUDY DESIGN

A time and motion study was conducted at three care settings within a large hospice and palliative care network and a process map was drawn to describe the personnel and activities recorded.

METHODS

Researchers recorded activities performed by clinical and administrative staff. Activities were categorized into those related to patient care, administrative duties, care coordination, and other. A process map of palliative care delivery was created and descriptive statistics were used to calculate the proportion of time spent on discrete activities and within each activity category.

RESULTS

Over 50 hours of activities were recorded during which the clinicians interacted with 25 patients and engaged in 20 distinct tasks. Physicians spent 94% of their time on tasks related to patient care and 1% on administrative tasks. Nurse practitioners and registered nurses spent 82% and 53% of their time on patient-related tasks and 2% and 37% on administrative tasks, respectively.

CONCLUSION

The delivery of palliative care is interdisciplinary and involves numerous discrete tasks and activities. Understanding the components of a community-based palliative care model is the first step to designing incentives to encourage its spread.

Restructuring hospitalist work schedules to improve care timeliness and efficiency

Background In 2014, we recognised that the pace of admissions frequently exceeded our ability to assign a hospitalist. Long patient wait times occurred at admission, especially for patients arriving in the late afternoon when hospitalist day shifts were ending. Our purpose was to redesign hospitalist schedules, duties and method of distributing admissions to match demand. Design We used administrative data to tabulate Hospital Medicine admission requests by time of day and identified mismatch between volume and capacity with the current staffing model. We determined that we needed to accommodate 29 admits per day with peak admission volume in the late afternoon and early evening. The current staffing model failed after 22 admits. To realign staffing around patient admissions, we organised a series of Lean quality improvements, starting with a 2-day event in July 2014, and followed by a series of Plan-Do-Study-Act (PDSA) cycles. The improvement team included hospitalists, residents and administrators, and each PDSA cycle involved collection of feedback from all affected providers. Strategy At baseline, our hospitalist group had six daytime and two nighttime services, including teaching services and attending-only services. Four of eight services were available for admissions, while four were rounding-only. Admitting capacity (patients per day) was 22. Through three PDSA cycles, we successively adapted our staffing and admitting model until the final staffing model aligned with patient admissions. The final model included different shift start times, use of all 10 shifts for admissions and addition of an Advanced Registered Nurse Practitioner (ARNP) service. Results Admitting capacity increased to 30. We confirmed success with follow-up data on patient wait times. Emergency department mean patient wait times for admission decreased 36% from 66 to 43 min (p<0.001). Conclusion Quantifying admission demand by time of day, then designing work schedules and duties around meeting this demand was an effective approach to reduce patient wait times.

Design of admission medication reconciliation technology: a human factors approach to requirements and prototyping

OBJECTIVE

Our objectives were to (1) develop an in-depth understanding of the workflow and information flow in medication reconciliation, and (2) design medication reconciliation support technology using a combination of rapid-cycle prototyping and human-centered design.

BACKGROUND

Although medication reconciliation is a national patient safety goal, limitations both of physical environment and in workflow can make it challenging to implement durable systems. We used several human factors techniques to gather requirements and develop a new process to collect a medication history at hospital admission.

METHODS

We completed an ethnography and time and motion analysis of pharmacists in order to illustrate the processes used to reconcile medications. We then used the requirements to design prototype multimedia software for collecting a bedside medication history. We observed how pharmacists incorporated the technology into their physical environment and documented usability issues.

RESULTS

Admissions occurred in three phases: (1) list compilation, (2) order processing, and (3) team coordination. Current medication reconciliation processes at the hospital average 19 minutes to complete and do not include a bedside interview. Use of our technology during a bedside interview required an average of 29 minutes. The software represents a viable proof-of-concept to automate parts of history collection and enhance patient communication. However, we discovered several usability issues that require attention.

CONCLUSIONS

We designed a patient-centered technology to enhance how clinicians collect a patient's medication history. By using multiple human factors methods, our research team identified system themes and design constraints that influence the quality of the medication reconciliation process and implementation effectiveness of new technology.

KEYWORDS

Evidence-based design, human factors, patient-centered care, safety, technology.

Measuring patient experiences on hospitalist and teaching services: Patient responses to a 30-day postdischarge questionnaire

BACKGROUND

Data comparing patient experiences between general medicine teaching and nonteaching hospitalist services are lacking.

OBJECTIVE

Evaluate hospitalized patients' experience on general medicine teaching and nonteaching hospitalist services by assessing patients' confidence in their ability to identify their physician(s), understand their roles, and their rating of the coordination and overall care.

METHODS

Retrospective cohort analysis of general medicine teaching and nonteaching hospitalist services from 2007 to 2013 at an academic medical center. Patients were surveyed 30-days after hospital discharge regarding their confidence in their ability to identify their physician(s), understand the role of their physician(s), and their perceptions of coordination and overall care. A 3-level, mixed effects logistic regression was performed to ascertain the association between service type and patient-reported outcomes.

RESULTS

Data from 4591 general medicine teaching and 1811 nonteaching hospitalist service patients demonstrated that those cared for by the hospitalist service were more likely to report being able to identify their physician (50% vs 45%, P < 0.001), understand their role (54% vs 50%, P < 0.001), and rate greater satisfaction with coordination (68 vs 64%, P = 0.006) and overall care (73% vs 67%, P < 0.001). In regression models, the hospitalist service was associated with higher ratings in overall care (odds ratio [OR]: 1.33; 95% confidence interval [CI]: 1.15-1.47), even when hospitalists were the attendings on general medicine teaching services (OR: 1.17; 95% CI: 1.01-1.31).

CONCLUSION

Patients on a nonteaching hospitalist service rated their overall care slightly better than patients on a general medicine teaching service. Team structure and complexity may play a role in this difference.

Emergency medicine resident physicians' perceptions of electronic documentation and workflow: a mixed methods study

OBJECTIVE

To understand emergency department (ED) physicians' use of electronic documentation in order to identify usability and workflow considerations for the design of future ED information system (EDIS) physician documentation modules.

METHODS

We invited emergency medicine resident physicians to participate in a mixed methods study using task analysis and qualitative interviews. Participants completed a simulated, standardized patient encounter in a medical simulation center while documenting in the test environment of a currently used EDIS. We recorded the time on task, type and sequence of tasks performed by the participants (including tasks performed in parallel). We then conducted semi-structured interviews with each participant. We analyzed these qualitative data using the constant comparative method to generate themes.

RESULTS

Eight resident physicians participated. The simulation session averaged 17 minutes and participants spent 11 minutes on average on tasks that included electronic documentation. Participants performed tasks in parallel, such as history taking and electronic documentation. Five of the 8 participants performed a similar workflow sequence during the first part of the session while the remaining three used different workflows. Three themes characterize electronic documentation: (1) physicians report that location and timing of documentation varies based on patient acuity and workload, (2) physicians report a need for features that support improved efficiency; and (3) physicians like viewing available patient data but struggle with integration of the EDIS with other information sources.

CONCLUSION

We confirmed that physicians spend much of their time on documentation (65%) during an ED patient visit. Further, we found that resident physicians did not all use the same workflow and approach even when presented with an identical standardized patient scenario. Future EHR design should consider these varied workflows while trying to optimize efficiency, such as improving integration of clinical data. These findings should be tested quantitatively in a larger, representative study.

Time motion studies in healthcare: what are we talking about?

Time motion studies were first described in the early 20th century in industrial engineering, referring to a quantitative data collection method where an external observer captured detailed data on the duration and movements required to accomplish a specific task, coupled with an analysis focused on improving efficiency. Since then, they have been broadly adopted by biomedical researchers and have become a focus of attention due to the current interest in clinical workflow related factors. However, attempts to aggregate results from these studies have been difficult, resulting from a significant variability in the implementation and reporting of methods. While efforts have been made to standardize the reporting of such data and findings, a lack of common understanding on what "time motion studies" are remains, which not only hinders reviews, but could also partially explain the methodological variability in the domain literature (duration of the observations, number of tasks, multitasking, training rigor and reliability assessments) caused by an attempt to cluster dissimilar sub-techniques. A crucial milestone towards the standardization and validation of time motion studies corresponds to a common understanding, accompanied by a proper recognition of the distinct techniques it encompasses. Towards this goal, we conducted a review of the literature aiming at identifying what is being referred to as "time motion studies". We provide a detailed description of the distinct methods used in articles referenced or classified as "time motion studies", and conclude that currently it is used not only to define the original technique, but also to describe a broad spectrum of studies whose only common factor is the capture and/or analysis of the duration of one or more events. To maintain alignment with the existing broad scope of the term, we propose a disambiguation approach by preserving the expanded conception, while recommending the use of a specific qualifier "continuous observation time motion studies" to refer to variations of the original method (the use of an external observer recording data continuously). In addition, we present a more granular naming for sub-techniques within continuous observation time motion studies, expecting to reduce the methodological variability within each sub-technique and facilitate future results aggregation.

The relationship between time spent communicating and communication outcomes on a hospital medicine service

BACKGROUND

Quality care depends on effective communication between caregivers, but it is unknown whether time spent communicating is associated with communication outcomes.

OBJECTIVE

To assess the association between time spent communicating, agreement on plan of care, and patient satisfaction.

DESIGN

Time-motion study with cross-sectional survey.

SETTING

Academic medical center.

PARTICIPANTS

Physicians, patients, and nurses on a hospital medicine service.

MEASUREMENTS

Hospitalists' forms of communication were timed with a stopwatch. Physician-nurse agreement on the plan of care and patient satisfaction with physician communication were assessed via survey.

RESULTS

Eighteen hospitalists were observed caring for 379 patients. On average, physicians spent more time per patient on written than verbal communication (median: 9.2 min. vs. 6.3 min, p<0.001). Verbal communication was greatest with patients (mean time 5.3 min, range 0-37 min), then other physicians (1.4 min), families (1.1 min), nurses (1.1 min), and case managers (0.4 min). There was no verbal communication with nurses in 30% of cases. Nurses and physicians agreed most about planned procedures (87%), principal diagnosis (74%), tests ordered (73%), anticipated discharge date (69%) and least regarding medication changes (59%). There was no association between time spent communicating and agreement on plan of care. Among 123 patients who completed surveys (response rate 32%), time physicians spent talking to patients was not correlated with patients' satisfaction with physician communication (Pearson correlation coefficient = 0.09, p=0.30).

CONCLUSIONS

Hospitalists vary in the amount of time they spend communicating, but we found no association between time spent and either patient satisfaction or nurse-physician agreement on plan of care.