Tips for saving time in the era of new work hour rules
From the September ACP Observer, copyright © 2004 by the American College of Physicians.
By Christine Kuehn Kelly
When patients at the University of Chicago Hospitals need a central line or a lumbar puncture, a member of the internal medicine team won't necessarily perform that service. Instead, a member of a special critical care procedures service—which includes rotating internal medicine residents—now performs many of those tasks.
In part, the medical center hopes the new critical care team will provide those services more efficiently. But the hospital has another motive in putting a new emphasis on teamwork: meeting the work hour rules for residents that were introduced in July of 2003.
"The service helps alleviate the resident's work load," said Vineet Arora, ACP Member, a fellow in hospital medicine at the University of Chicago, "and gets the work done more quickly."
As new rules limiting the resident work hours pass their first-year mark, residency programs everywhere are searching for ways to balance their service and continuity of care needs with the training needs of housestaff. At some institutions, attendings are being asked to increase their workload to offset fewer resident duty hours. And residents are finding that service requirements are leaving less time for conferences and elective rotations.
A number of programs have discovered, however, that by building better teams in their training programs, housestaff can continue to care for patients and meet their educational objectives. From teaching housestaff how to work together more efficiently to streamlining communication to avoid problems with handoffs, training programs are finding ways to comply with the new rules without eating into residents' educational time.
Saving time through teamwork
First and foremost, putting a greater emphasis on teamwork can help save time. Basic strategies call for residents to help each other with tasks like ordering tests and services, and with following up to retrieve information.
"To save time, we encourage team members to help each other as much as possible on rounds," said Cassie C. Kennedy, ACP Member, a pulmonary and critical care medicine fellow at Mayo Clinic in Rochester, Minn. "If one intern is presenting and the team says, 'Let's order a CAT scan,' the other intern will get the order book out."
To save time, have teams run labs in the morning and at noon and go to radiology only once a day.
To stop residents from wasting time making repeated trips to the lab or radiology, Donald W. Brady, ACP Member, co-director of the internal medicine program at Emory University School of Medicine in Atlanta, recommended a technique known as group tasking: The team runs labs in the morning and at noon and goes to radiology only once a day. To make the most of residents' limited time, he suggested sending just one team member to check results.
"The resident can't be the only one taking care of the team," Dr. Brady said. "We have to think more in terms of a team structure to get things done."
Residents at the Atlanta VA Medical Center went one step further, instituting a new team activity: early morning "work rounds." Residents, interns and medical students—but not attendings—briefly see every patient on their service; review charts, consults and treatment plans; and together formulate a care plan for the day.
"These four-to-five minute work rounds help us see problems early on and make sure everyone on the team is on the same page," said chief internal medicine resident David C. Huneycutt, ACP Associate. According to a survey, residents rated work rounds as, Dr. Huneycutt said, "their No. 1 time saver."
Working with medical students
Resident duty hour restrictions may leave some medical students feeling short-changed—a problem that programs can solve, said Nilam Soni, ACP Associate, chief internal medicine resident at Presbyterian Hospital of Dallas, by making students working members of the team.
"Residents feel more obliged to teach students who are helping with procedures," he said. One strategy is to let students, interns and residents share examinations and their findings. "If they do it together," Dr. Soni explained, "they can almost 'tag team' the work and spell each other during patient handoffs."
At the same time, residents need to learn how to be managers and delegate. Senior residents who need to attend a conference, for example, should try delegating some duties to other team members. "You need to learn what can be delegated, what your team members can learn and what duties you need to take care of yourself," said Emory's Dr. Brady. Then follow up and provide feedback.
Electronic tools can help you manage information and save time. When residents need to send brief messages to each other, Dr. Soni suggested using a pager to communicate. "You can let interns know a patient's labs were normal or there was another finding," he explained. Sending messages via e-mail is another way to make sure everyone is quickly notified of policy or schedule changes when residents are at home and off their beepers.
Voicemail can be a time-saver when residents use it to order tests in the late evening hours when diagnostic services are closed. "The more you can do the night before postcall, the better organized you will be the next day," said the University of Chicago's Dr. Arora.
Keeping up with written notes is also important. As you finish working up a patient, add that patient to your sign-out sheet or template. Update patient information routinely—and constantly think about the handoff.
"You will be creating the building blocks that keep you from sitting down at 1:45 in the afternoon trying to get everything done," Dr. Arora said.
Communication issues inevitably lead to concerns about continuity of care. Well-designed systems to handle sign-outs and discharges can help, but even the best system won't replace good communication among team members.
A face-to-face meeting allows the incoming resident to ask questions and discuss concerns. "One of the ways to transfer information is to create sign-out rounds supervised by a senior resident or attending, along with computerized sign-out forms," said Richard J. Keating, ACP Associate, chief internal medicine resident at the Mayo Clinic.
The problem with 'workarounds'
Working around a patient transport problem by taking a patient to radiology may be easier than dealing with hospital administration. The problem? The "workaround" approach slows you and other members of your team down.
With duty hours reduced, using residents for patient transport and ancillary services is a critical concern. In a survey reported in the September 2003 issue of Academic Medicine, researchers found that residents in all disciplines devoted as much as 35% of their time to delivering patient care with either marginal or no educational value.
"Residents are good at finding ways to work around the system," Dr. Arora said. "The problem is that it creates bottlenecks and keeps issues from being resolved."
The quality improvement team at Dr. Arora's hospital realized, for instance, that residents were trying to get lab results sooner by ordering many of their labs stat—which paradoxically slowed the system down. To counter the trend, the team created an educational campaign on how to order during set sweep times. "This helped decrease the number of stat labs and made the order system more efficient," she said.
And after they've demonstrated competence in routine procedures, residents can save time by calling in experienced ancillary staff for procedures such as drawing blood or intubating patients. Institutions should also identify those routines that residents perform more frequently than needed for educational purposes and see that they are carried out by appropriate ancillary staff.
Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.
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