How Much Time are Physicians and Nurses Spending Together at the Patient Bedside?

Physician behaviors associated with increased physician and nurse communication during bedside interdisciplinary rounds

BACKGROUND

Effective team communication during interdisciplinary rounds (IDRs) is a hallmark of safe, efficient, patient-centered care. However, there is limited understanding of optimal IDR structures and procedures.

OBJECTIVE

This study aimed to analyze direct observations of physician and nurse interactions during bedside IDR to identify behaviors associated with increased interprofessional communication.

DESIGNS, SETTINGS AND PARTICIPANTS

Trained observers audited general medicine ward rounds at an academic medical center using a standardized tool to record physician and nurse behavior and communication in 1007 patient encounters in October 2019 to March 2020.

RESULTS

There were significant differences in physician and nurse interaction time among physicians with different levels of training, with attendings demonstrating higher interaction time than residents (5.4 ± 4.6 vs. 4.3 ± 3.7 min, p = .02) and interns or medical students (3.0 ± 3.2 min, p = .002). Attendings were more likely to initiate a conversation about nurse concerns (76.9%) compared to residents (67.9%) and interns or medical students (59.3%, p = .03). Early nurse participation in bedside visits was associated with increased physician and nurse interaction time (5.0 ± 4.6 vs. 1.9 ± 1.7 min, p < .001) and physician initiative to ask about nurse concerns (74.8% vs. 64.3%, p = .04). In addition, physician initiative to ask the nurse for concerns rather than waiting for the nurse to offer concerns without being prompted was associated with a subsequent conversation about those concerns (74.5% vs. 61.8%, p < .001) and the physician asking about patient or family concerns (94.2% vs. 88.4%, p = .01).

CONCLUSIONS

Implementing IDR structures and procedures that promote attending physician involvement, physician initiative, and early nurse participation could optimize interdisciplinary communication and quality of care.

Frontline healthcare workers' perspectives on interprofessional teamwork during COVID-19

Effective interprofessional teamwork serves an important role in successful crisis response. Responses to past public health crises have relied on interprofessional communication and trust to support healthcare worker (HCW) resiliency. To understand interprofessional interactions and perceptions of teamwork during the COVID-19 response, we conducted in-depth semi-structured interviews with 18 inpatient HCWs (11 bedside nurses, 5 care coordinators, and 2 pharmacists) from one VA Medical Center between March and June 2020. Using thematic analysis, we identified four key themes that describe the strengths and challenges of interprofessional teamwork, communication, patient care, and organizational response during the initial COVID-19 surge. Interprofessional teams were fragmented. HCWs who transitioned to remote work lost their status on inpatient teams and struggled to provide pre-pandemic levels of quality of care. Conversely, interprofessional teamwork improved for HCWs who continued to work on inpatient units, where study participants described a decline in interprofessional hierarchies and an increase in mutual support. Participants described the need for timely, accurate, transparent communication as they faced new patient safety and communication challenges brought on by the pandemic. HCWs expressed a desire for sustained leadership support and inclusion in institutional decision-making. The challenges to teamwork, communication, and patient care reported in this study highlight the need for consistent, transparent communication and organizational response from hospital leadership during times of crisis.

A socio-technical systems analysis of the application of RFID-enabled technology to the transport of precious laboratory samples in a large acute teaching hospital

The scale and pace of improvement in patient safety in healthcare has been unacceptably slow. A paucity of research into the application of systems-thinking concepts and a failure to appreciate health systems complexity are cited as barriers to sustainable health systems improvement. This study reports on a socio-technical systems analysis, called the CUBE, of the characteristics of a large acute teaching hospital's system for the transport of precious specimens, a system enabled by radio-frequency identification tracking technology. The CUBE proved itself to be an effective analytic tool. The analysis provided a constructive framework to link diverse data and documentation; explicitly inviting consideration of the roles and understandings of different stakeholders; as well as broader cultural factors that could influence current or future activity. The analysis also supported recommendations to improve and extend operations. This study supports the argument for systems understanding and systems thinking being at the core of new approaches to patient safety.

Nursing Workflow Change in a COVID-19 Inpatient Unit Following the Deployment of Inpatient Telehealth: Observational Study Using a Real-Time Locating System

BACKGROUND

The COVID-19 pandemic prompted widespread implementation of telehealth, including in the inpatient setting, with the goals to reduce potential pathogen exposure events and personal protective equipment (PPE) utilization. Nursing workflow adaptations in these novel environments are of particular interest given the association between nursing time at the bedside and patient safety. Understanding the frequency and duration of nurse-patient encounters following the introduction of a novel telehealth platform in the context of COVID-19 may therefore provide insight into downstream impacts on patient safety, pathogen exposure, and PPE utilization.

OBJECTIVE

The aim of this study was to evaluate changes in nursing workflow relative to prepandemic levels using a real-time locating system (RTLS) following the deployment of inpatient telehealth on a COVID-19 unit.

METHODS

In March 2020, telehealth was installed in patient rooms in a COVID-19 unit and on movable carts in 3 comparison units. The existing RTLS captured nurse movement during 1 pre- and 5 postpandemic stages (January-December 2020). Change in direct nurse-patient encounters, time spent in patient rooms per encounter, and total time spent with patients per shift relative to baseline were calculated. Generalized linear models assessed difference-in-differences in outcomes between COVID-19 and comparison units. Telehealth adoption was captured and reported at the unit level.

RESULTS

Change in frequency of encounters and time spent per encounter from baseline differed between the COVID-19 and comparison units at all stages of the pandemic (all P<.001). Frequency of encounters decreased (difference-in-differences range -6.6 to -14.1 encounters) and duration of encounters increased (difference-in-differences range 1.8 to 6.2 minutes) from baseline to a greater extent in the COVID-19 units relative to the comparison units. At most stages of the pandemic, the change in total time nurses spent in patient rooms per patient per shift from baseline did not differ between the COVID-19 and comparison units (all P>.17). The primary COVID-19 unit quickly adopted telehealth technology during the observation period, initiating 15,088 encounters that averaged 6.6 minutes (SD 13.6) each.

CONCLUSIONS

RTLS movement data suggest that total nursing time at the bedside remained unchanged following the deployment of inpatient telehealth in a COVID-19 unit. Compared to other units with shared mobile telehealth units, the frequency of nurse-patient in-person encounters decreased and the duration lengthened on a COVID-19 unit with in-room telehealth availability, indicating "batched" redistribution of work to maintain total time at bedside relative to prepandemic periods. The simultaneous adoption of telehealth suggests that virtual care was a complement to, rather than a replacement for, in-person care. However, study limitations preclude our ability to draw a causal link between nursing workflow change and telehealth adoption. Thus, further evaluation is needed to determine potential downstream implications on disease transmission, PPE utilization, and patient safety.

How is mobile health technology transforming physician-nurse collaboration?

The integration of mobile health technologies in medical practice has the potential to promote in-person, high-quality care. We examine the impact of Voalte, a healthcare-specific mobile application, on bedside rounding and care coordination. A cross-sectional survey was conducted on 71 medical ward-based nurses from a quaternary-care academic centre, capturing 183 rounding events. The frequency of physician-nurse overlap at the bedside was 50.3%, representing a >20% increase when compared with the 2018 baseline before Voalte's introduction. Our results show that mobile health technologies can strengthen inpatient medicine workflows and interdisciplinary collaboration when implemented successfully.

Using a Real-Time Locating System to Evaluate the Impact of Telemedicine in an Emergency Department During COVID-19: Observational Study

BACKGROUND

Telemedicine has been deployed by health care systems in response to the COVID-19 pandemic to enable health care workers to provide remote care for both outpatients and inpatients. Although it is reasonable to suspect telemedicine visits limit unnecessary personal contact and thus decrease the risk of infection transmission, the impact of the use of such technology on clinician workflows in the emergency department is unknown.

OBJECTIVE

This study aimed to use a real-time locating system (RTLS) to evaluate the impact of a new telemedicine platform, which permitted clinicians located outside patient rooms to interact with patients who were under isolation precautions in the emergency department, on in-person interaction between health care workers and patients.

METHODS

A pre-post analysis was conducted using a badge-based RTLS platform to collect movement data including entrances and duration of stay within patient rooms of the emergency department for nursing and physician staff. Movement data was captured between March 2, 2020, the date of the first patient screened for COVID-19 in the emergency department, and April 20, 2020. A new telemedicine platform was deployed on March 29, 2020. The number of entrances and duration of in-person interactions per patient encounter, adjusted for patient length of stay, were obtained for pre- and postimplementation phases and compared with t tests to determine statistical significance.

RESULTS

There were 15,741 RTLS events linked to 2662 encounters for patients screened for COVID-19. There was no significant change in the number of in-person interactions between the pre- and postimplementation phases for both nurses (5.7 vs 7.0 entrances per patient, P=.07) and physicians (1.3 vs 1.5 entrances per patient, P=.12). Total duration of in-person interactions did not change (56.4 vs 55.2 minutes per patient, P=.74) despite significant increases in telemedicine videoconference frequency (0.6 vs 1.3 videoconferences per patient, P<.001 for change in daily average) and duration (4.3 vs 12.3 minutes per patient, P<.001 for change in daily average).

CONCLUSIONS

Telemedicine was rapidly adopted with the intent of minimizing pathogen exposure to health care workers during the COVID-19 pandemic, yet RTLS movement data did not reveal significant changes for in-person interactions between staff and patients under investigation for COVID-19 infection. Additional research is needed to better understand how telemedicine technology may be better incorporated into emergency departments to improve workflows for frontline health care clinicians.

[Prevalence of anxiety among health professionals in times of COVID-19: a systematic review with meta-analysis]

This study sets out to identify the prevalence of anxiety among health professionals during the COVID-19 pandemic. It involves a systematic review and meta-analysis of studies published in any language in 2020. A search was conducted in the Embase, LILACS and PubMed databases using the keywords anxiety, COVID-19, health workers, and synonyms. The estimated overall prevalence of anxiety with a 95% confidence interval was calculated using the random effects model. Of the 861 records identified, 36 articles were included in the systematic review and 35 in the meta-analysis. The overall prevalence of anxiety was 35% (95%CI: 29-40). A higher risk of anxiety was identified among women compared to men (Odds Ratio: 1.64 [95%CI: 1.47-1.84]), and in nurses, in comparison with physicians (Odds Ratio: 1.19 [95%CI: 1.07-1.33]). Being on the front line of COVID-19, being infected with coronavirus and having chronic diseases were also factors associated with a higher risk of anxiety. A high prevalence of anxiety among health professionals was observed, with higher risk among women and nurses. There is a pressing need for measures aimed at prevention of anxiety and providing early and appropriate treatment for those suffering from moderate and severe anxiety.