A Time Motion Study Evaluating the Impact of Geographic Cohorting of Hospitalists

Closer to or Farther away from an Ideal Model of Care? Lessons Learned from Geographic Cohorting

Geographic "cohorting," "co-location," "regionalization," or "localization" refers to the assignation of a hospitalist team to a specific inpatient unit. Its benefits may be related to the formation of a team and the additional interventions like interdisciplinary rounding that the enhanced proximity facilitates. However, cohorting is often adopted in isolation of the bundled approach within which it has proven beneficial. Cohorting may also be associated with unintended consequences such as increased interruptions and increased indirect care time. Institutions may increase patient loads in anticipation of the efficiency gained by cohorting-leading to further increases in interruptions and time away from the bedside. Fragmented attention and increases in indirect care may lead to a perception of increased workload, errors, and burnout. As hospital medicine evolves, there are lessons to be learned by studying cohorting. Institutions and inpatient units should work in synergy to shape the day-to-day work which directly affects patient and clinician outcomes-and ultimately culminates in the success or failure of the parent organization. Such synergy can manifest in workflow design and metric selection. Attention to workloads and adopting the principles of continuous quality improvement are also crucial to developing models of care that deliver excellent care.

The impact of surge adaptations on hospitalist care teams during the COVID-19 pandemic utilizing a rapid qualitative analysis approach

Background

Hospital systems have rapidly adapted to manage the influx of patients with COVID-19 and hospitalists, specialists in inpatient care, have been at the forefront of this response, rapidly adapting to serve the ever-changing needs of the community and hospital system. Institutional leaders, including clinical care team members and administrators, deployed many different strategies (i.e. adaptations) to manage the influx of patients. While many different strategies were utilized in hospitals across the United States, it is unclear how frontline care teams experienced these strategies and multifaceted changes. As these surge adaptations likely directly impact clinical care teams, we aimed to understand the perceptions and impact of these clinical care and staffing adaptations on hospitalists and care team members in order to optimize future surge plans.

Methods

Qualitative, semi-structured interviews and focus groups with hospitalist physicians, advanced practice providers (APPs), and hospital nursing and care management staff at a quaternary academic medical center. Interviews focused on the impact of COVID-19 surge practices on the following areas: (1) the experience of clinical care teams with the adaptations used to manage the surge (2) the perception and experience with the communication strategies utilized (3) the personal experience with the adaptations (i.e. how they impacted the individual) and (4) if participants had recommendations on strategies for future surges. We utilized rapid qualitative analysis methods to explore themes and subthemes.

Results

We conducted five focus groups and 21 interviews. Three themes emerged from the work including (1) dynamic clinical experience with a lot of uncertainty, (2) the importance of visible leadership with a focus on sense-making, and (3) the significant emotional toll on care team members. Subthemes included sufficient workforce, role delineation and training, information sharing, the unique dichotomy between the need for flexibility and the need for structure, the importance of communication, and the emotional toll not only on the provider but their families. Several recommendations came from this work.

Conclusions

COVID-19 surge practices have had direct impact on hospitalists and care team members. Several tactics were identified to help mitigate the many negative effects of COVID-19 on frontline hospitalist providers and care teams.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00804-7.

Mobile technology for hospitalists: Clinician perspectives and unmet needs from a workflow analysis

Background

The hospitalist workday is cognitively demanding and dominated by activities away from patients’ bedsides. Although mobile technologies are offered as solutions, clinicians report lower expectations of mobile technology after actual use.

Objective

The purpose of this study is to better understand opportunities for integrating mobile technology and apps into hospitalists’ workflows. We aim to identify difficult tasks and contextual factors that introduce inefficiencies and characterize hospitalists’ perspectives on mobile technology and apps.

Methods

We conducted a workflow analysis based on semistructured interviews. At a Midwestern US medical center, we recruited physicians and nurse practitioners from hospitalist and inpatient teaching teams and internal medicine residents. Interviews focused on tasks perceived as frequent, redundant, and difficult. Additionally, participants were asked to describe opportunities for mobile technology interventions. We analyzed contributing factors, impacted workflows, and mobile app ideas.

Results

Over 3 months, we interviewed 12 hospitalists. Participants collectively identified chart reviews, orders, and documentation as the most frequent, redundant, and difficult tasks. Based on those tasks, the intake, discharge, and rounding workflows were characterized as difficult and inefficient. The difficulty was associated with a lack of access to electronic health records at the bedside. Contributing factors for inefficiencies were poor usability and inconsistent availability of health information technology combined with organizational policies. Participants thought mobile apps designed to improve team communications would be most beneficial. Based on our analysis, mobile apps focused on data entry and presentation supporting specific tasks should also be prioritized.

Conclusions

Based on our results, there are prioritized opportunities for mobile technology to decrease difficulty and increase the efficiency of hospitalists’ workflows. Mobile technology and task-specific mobile apps with enhanced usability could decrease overreliance on hospitalists’ memory and fragmentation of clinical tasks across locations. This study informs the design and implementation processes of future health information technologies to improve continuity in hospital-based medicine.

Preferences to improve rounding efficiency amongst hospitalists: a survey analysis

Background: There is no ‘gold standard’ method of rounding for hospitalists. This study investigates hospitalist rounding preferences to improve efficiency based on resources categorized under work assignment and communication.

Methods: An anonymous survey containing demographics and questions on preferences for rounding efficiently by hospitalists were widely distributed online. Res6ponses were presented using descriptive statistics and SPSS v26.

Results: There were 143 respondents, majority male (60%) with (40%) female. Most (80%) expect higher patient volumes when working with an advanced practitioner (AP). Half (50%) preferred rounding independently, (34%) with an AP, and majority (62%) with a resident. Geographic rounding was most efficient at 85%. Text messaging for paging was preferred (70.1%) to pagers (23.4%). Respondents preferred calling a consultant (52%) or text messaging (40%). Majority have not used a WOW yet (74%) believe WOWs could improve efficiency. Majority prefer dictation via Dragon (47%) to the phone application (23%). Only 29% believe their EMR is too complex to navigate. Preference difference due to age was insignificant.

Discussion and Conclusion: In this study, 143 hospitalists provided preferences for improving rounding efficiency based on elements from work assignment and communication. This analysis can provide insights on designing best practices for hospitalists rounding efficiently.

Impact of Geographical Cohorting in the ICU: An Academic Tertiary Care Center Experience

Supplemental Digital Content is available in the text.

ICU is a multifaceted organization where multiple teams care for critically ill patients. In the current era, collaboration between teams and efficient workflows form the backbone of value-based care. Geographical cohorting is a widespread model for hospitalist rounding, but its role in ICUs is unclear. This study evaluates the outcomes of geographical cohorting in a large ICU of an Academic Health Center.