Background: Regionalization of medical teams has the potential to improve interdisciplinary communication and efficiency but this must outweigh any logistical downsides and resource requirements. For example, full regionalization must be paired with some method of daily admitting; however the impact of regionalization and daily admitting on intern workflow is not known. We hypothesized that regionalization and daily admitting would reduce the time trainees spent in non-value added activities and leave more time for patient care.
Methods: The general medicine teams at one academic medical center were reorganized into daily admitting unit-based care teams, with day and evening roles that overlap in the afternoon to facilitate patient handoffs and teaching. Time-motion analysis of interns was conducted and consisted of 18 pre- and 18 post-implementation observation sessions, matched for time of year. These observations were representative of each day of the 4-day call cycle and both day and evening roles. Trained observers used a tablet linked to a customized Microsoft Access database to dynamically track the amount of time spent in 124 unique activities, which were grouped into patient care, education, non-value added activity (e.g. transit between units), and personal time. Primary outcomes included the proportion of time spent in each group. Secondary outcomes included the proportion of time spent in subgroup activities and the number of pages received per hour. Data were analyzed by linear regression utilizing generalized estimating equations to account for clustering by intern.
Results: Implementation of regionalization and daily admitting decreased the proportion of time spent in non-value added activities, including a decrease in transit time (Table). Interns spent more time in direct patient care while admitting, in face to face communication with other members of the interdisciplinary team, and less time communicating by phone, paging, and email. The number of pages received per hour by interns decreased. The time spent in education activities, including conferences and team teaching sessions, did not change.
Conclusions: This study demonstrates that creation of daily admitting unit-based care teams can reduce the time that interns spend performing non-value added activities, which prior to implementation was as great as the amount spent in direct patient care (12.5%, or 75 minutes of a typical 10-hour day). It can also promote high value activities such as time with patients during an admission and face to face communication with other providers. Although the magnitude of these changes is modest, their importance may be substantial, e.g., as face to face communication can be more effective than other modes, and communication failures are often at the root of many medical errors.