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Geographic cohorting increased direct care time and interruptions
Background: Geographic cohorting localizes hospitalist teams to a single unit. It has previously been shown to improve outcomes.
Design: Prospective time and motion study.
Setting: 11 geographically cohorted services and 4 noncohorted teams at Indiana University Health, a large academic medical center.
Synopsis: Geotracking was used to monitor time spent inside and outside of patient rooms for 17 hospitalists over at least 6 weeks. Eight hospitalists were also directly observed. Both groups spent roughly three times more time outside patient rooms than inside. Geographic cohorting was associated with longer patient visits (ranging from 69.6 to 101.7 minutes per day depending on team structure) and a higher percentage of time in patient rooms. Interruptions were more common with geographic cohorting. These hospitalists were interrupted every 14 minutes in the morning and every 8 minutes in the afternoon. Of these interruptions, 62% were face-to-face, 25% were electronic, and 13% were both simultaneously.
An important limitation of this study is that the investigators did not evaluate clinical outcomes or provider satisfaction. This may give some pause to the widespread push toward geographic cohorting.
Bottom line: More frequent interruptions may partially offset potential increases in patient-hospitalist interactions achieved through geographic cohorting.
Citation: Kara A et al. A time motion study evaluating the impact of geographic cohorting of hospitalists. J Hosp Med. 2020;15:338-44.
Dr. Sweigart is a hospitalist at the Lexington (Ky.) VA Health Care System.
Background: Geographic cohorting localizes hospitalist teams to a single unit. It has previously been shown to improve outcomes.
Design: Prospective time and motion study.
Setting: 11 geographically cohorted services and 4 noncohorted teams at Indiana University Health, a large academic medical center.
Synopsis: Geotracking was used to monitor time spent inside and outside of patient rooms for 17 hospitalists over at least 6 weeks. Eight hospitalists were also directly observed. Both groups spent roughly three times more time outside patient rooms than inside. Geographic cohorting was associated with longer patient visits (ranging from 69.6 to 101.7 minutes per day depending on team structure) and a higher percentage of time in patient rooms. Interruptions were more common with geographic cohorting. These hospitalists were interrupted every 14 minutes in the morning and every 8 minutes in the afternoon. Of these interruptions, 62% were face-to-face, 25% were electronic, and 13% were both simultaneously.
An important limitation of this study is that the investigators did not evaluate clinical outcomes or provider satisfaction. This may give some pause to the widespread push toward geographic cohorting.
Bottom line: More frequent interruptions may partially offset potential increases in patient-hospitalist interactions achieved through geographic cohorting.
Citation: Kara A et al. A time motion study evaluating the impact of geographic cohorting of hospitalists. J Hosp Med. 2020;15:338-44.
Dr. Sweigart is a hospitalist at the Lexington (Ky.) VA Health Care System.
Background: Geographic cohorting localizes hospitalist teams to a single unit. It has previously been shown to improve outcomes.
Design: Prospective time and motion study.
Setting: 11 geographically cohorted services and 4 noncohorted teams at Indiana University Health, a large academic medical center.
Synopsis: Geotracking was used to monitor time spent inside and outside of patient rooms for 17 hospitalists over at least 6 weeks. Eight hospitalists were also directly observed. Both groups spent roughly three times more time outside patient rooms than inside. Geographic cohorting was associated with longer patient visits (ranging from 69.6 to 101.7 minutes per day depending on team structure) and a higher percentage of time in patient rooms. Interruptions were more common with geographic cohorting. These hospitalists were interrupted every 14 minutes in the morning and every 8 minutes in the afternoon. Of these interruptions, 62% were face-to-face, 25% were electronic, and 13% were both simultaneously.
An important limitation of this study is that the investigators did not evaluate clinical outcomes or provider satisfaction. This may give some pause to the widespread push toward geographic cohorting.
Bottom line: More frequent interruptions may partially offset potential increases in patient-hospitalist interactions achieved through geographic cohorting.
Citation: Kara A et al. A time motion study evaluating the impact of geographic cohorting of hospitalists. J Hosp Med. 2020;15:338-44.
Dr. Sweigart is a hospitalist at the Lexington (Ky.) VA Health Care System.
Open ICUs giveth and taketh away
Background: Some academic medical centers and many community centers use “open” ICU models in which primary services longitudinally follow patients into the ICU with intensivist comanagement.
Design: Semistructured interviews with 12 hospitalists and 8 intensivists.
Setting: Open 16-bed ICUs at the University of California, San Francisco. Teams round separately at the bedside and are informally encouraged to check in daily.
Synopsis: The authors iteratively developed the interview questions. Participants were selected using purposive sampling. The main themes were communication, education, and structure. Communication was challenging among teams as well as with patients and families. The open ICU was felt to affect handoffs and care continuity positively. Hospitalists focused more on longitudinal relationships, smoother transitions, and opportunities to observe disease evolution. Intensivists focused more on fragmentation during the ICU stay and noted cognitive disengagement among some team members with certain aspects of patient care. Intensivists did not identify any educational or structural benefits of the open ICU model.
This is the first qualitative study of hospitalist and intensivist perceptions of the open ICU model. The most significant limitation is the risk of bias from the single-center design and purposive sampling. These findings have implications for other models of medical comanagement.
Bottom line: Open ICU models offer a mix of communication, educational, and structural barriers as well as opportunities. Role clarity may help optimize the open ICU model.
Citation: Santhosh L and Sewell J. Hospital and intensivist experiences of the “open” intensive care unit environment: A qualitative exploration. J Gen Intern Med. 2020;35(8):2338-46.
Dr. Sweigart is a hospitalist at the Lexington (Ky.) VA Health Care System.
Background: Some academic medical centers and many community centers use “open” ICU models in which primary services longitudinally follow patients into the ICU with intensivist comanagement.
Design: Semistructured interviews with 12 hospitalists and 8 intensivists.
Setting: Open 16-bed ICUs at the University of California, San Francisco. Teams round separately at the bedside and are informally encouraged to check in daily.
Synopsis: The authors iteratively developed the interview questions. Participants were selected using purposive sampling. The main themes were communication, education, and structure. Communication was challenging among teams as well as with patients and families. The open ICU was felt to affect handoffs and care continuity positively. Hospitalists focused more on longitudinal relationships, smoother transitions, and opportunities to observe disease evolution. Intensivists focused more on fragmentation during the ICU stay and noted cognitive disengagement among some team members with certain aspects of patient care. Intensivists did not identify any educational or structural benefits of the open ICU model.
This is the first qualitative study of hospitalist and intensivist perceptions of the open ICU model. The most significant limitation is the risk of bias from the single-center design and purposive sampling. These findings have implications for other models of medical comanagement.
Bottom line: Open ICU models offer a mix of communication, educational, and structural barriers as well as opportunities. Role clarity may help optimize the open ICU model.
Citation: Santhosh L and Sewell J. Hospital and intensivist experiences of the “open” intensive care unit environment: A qualitative exploration. J Gen Intern Med. 2020;35(8):2338-46.
Dr. Sweigart is a hospitalist at the Lexington (Ky.) VA Health Care System.
Background: Some academic medical centers and many community centers use “open” ICU models in which primary services longitudinally follow patients into the ICU with intensivist comanagement.
Design: Semistructured interviews with 12 hospitalists and 8 intensivists.
Setting: Open 16-bed ICUs at the University of California, San Francisco. Teams round separately at the bedside and are informally encouraged to check in daily.
Synopsis: The authors iteratively developed the interview questions. Participants were selected using purposive sampling. The main themes were communication, education, and structure. Communication was challenging among teams as well as with patients and families. The open ICU was felt to affect handoffs and care continuity positively. Hospitalists focused more on longitudinal relationships, smoother transitions, and opportunities to observe disease evolution. Intensivists focused more on fragmentation during the ICU stay and noted cognitive disengagement among some team members with certain aspects of patient care. Intensivists did not identify any educational or structural benefits of the open ICU model.
This is the first qualitative study of hospitalist and intensivist perceptions of the open ICU model. The most significant limitation is the risk of bias from the single-center design and purposive sampling. These findings have implications for other models of medical comanagement.
Bottom line: Open ICU models offer a mix of communication, educational, and structural barriers as well as opportunities. Role clarity may help optimize the open ICU model.
Citation: Santhosh L and Sewell J. Hospital and intensivist experiences of the “open” intensive care unit environment: A qualitative exploration. J Gen Intern Med. 2020;35(8):2338-46.
Dr. Sweigart is a hospitalist at the Lexington (Ky.) VA Health Care System.