실시간 위치확인 시스템을 활용한 병동회진시 의사의 이동패턴 : 파일럿 연구

A real-time locating system observes physician time-motion patterns during walk-rounds: a pilot study

David R Ward1†, William A Ghali2,3†, Alecia Graham3† and Jane B Lemaire1,3*†

Background

회진(Walk-rounds)는 의학교육에 있어서 흔히 활용되는 방법으로, 병실 바깥에서 그리고 병실 안 환자 옆에서 이뤄지는 교육이 혼합된 형태이다. 이 중 후자는 BST라고 불리며, 환자와 직접 접촉을 함으로써 의료진에 대한 환자의 인식을 향상시키는 장점을 비롯하여 다양한 장점이 있다.

Walk-rounds, a common component of medical education, usually consist of a combination of teaching outside of the patient room as well as in the presence of the patient. The latter is known as bedside teaching and the documented benefits of this method of interacting with patients include...

• improved patient-reported perception of medical teams, 
• increased learner opportunities for development of communication and physical examination skills, and 
• improved attending physician interactions with patients and allied healthcare personnel [1-5]. 

그러나 연구 결과를 보면 이러한 교육 방법을 점차 덜 활용하고 있어서 1960년대에는 75%였던 것이 최근에는 15-30%로 감소하였다. 그 이유로는 아마도 임상업무가 늘어나고 복잡해지면서 시간적 여유가 부족해진 것이 한 가지 이유이고, 그 외에도 여러가지 것들이 있다.

However, studies have consistently shown decreased utilization rates of these educational techniques in recent decades; from nearly 75% in the 1960’s to 15-30% in more recent literature [6,7]. Potential reasons for this include...

• time constraints due to increased case load and complexity, 
• increased time spent away from the bedside due to reliance on technology such as computerized physician order entry systems to assist with physician workflow, 
• lack of faculty experience and training in how to conduct bedside teaching rounds, and 
• perceived or actual decreased efficiency in daily time-management due to the process of team walk- rounds [8-11].

많은 연구들이 의료현장에서의 효율을 높이고 흐름을 원활히하는 것에 집중되고 있다. 업무 흐름은 지금까지는 관찰 또는 후향적 설문 등을 주로 활용했는데 이는 bias에 취약하다. 회진은 의사 업무 흐름의 한 부분임에도 의사들이 회진을 하는 동안 실시간으로 어떻게 움직이는지를 연구한 논문은 거의 없다. 최근 실시간 위치확인 시스템(RTLS)기술을 도입하면 환자/자재/직원의 흐름을 파악하여 업무흐름을 향상시키고 재정적, 시간적 절약도 가능하다. 

Much research has focused on ways to improve healthcare workplace efficiency and flow [12-15]. Investigations into physician workflow in particular have previously required direct observation or retrospective surveys, predisposing them to bias [16-19]. Although walk-rounds are inherently a component of physician workflow, there is a paucity of literature documenting the real-time movements of physicians during walk- rounds. Recently, use of novel real-time locating systems (RTLS) technologies to assist in management of patients, supplies, and staff have been advocated to improve healthcare provider workflow, potentially leading to financial and time savings [20]. Our local health authority engaged in related research by installing a RTLS and systematically evaluating its capabilities in locating and tracking items and people as well as the value of this technology to staff [21].

우리는 RTLS를 사용하여 내과 교육유닛(MTU)에서 의사들의 이동 패턴을 연구하였다. 

As a pilot sub-study of this work, we sought to use RTLS to observe and track the patterns of movement of staff physicians on an internal medicine Medical Teaching Unit (MTU) during a special Thursday morning rounding period. Thursday afternoons are protected as an academic half-day for all trainees in our residency training program, and as a result, there is a need to complete all or most clinical patient care duties in a compressed half-day that must end at noon. There has been considerable discussion among clinical preceptors and the directorship in our training program regarding the optimal approach to managing patient care in this compressed half day. Because of this, there is special interest in studying rounding patterns on Thursday morning walk-rounds, and more specifically the time-motion activities of various clinical preceptors. The resulting RTLS time-motion profiles give insight into varying staff physician work patterns.

METHODS:

During a project to assess the efficacy of RTLS technology to track equipment and patients in a clinical setting, we conducted a small-scale pilot study to observe attending physician walk-round patterns during a mandatory once-weekly team rounding session. A consecutive sample of attending physicians on the unit was targeted, eight agreed to participate. Data collected using the RTLS were pictorially represented as linked points overlaying a floor plan of the unit to represent each physician's motion through time. Visual analysis of time-motion was independently performed by two researchers and disagreement resolved through consensus. Rounding events were described as a sequence of approximate proportions of time engaged within or outside patient rooms.

RESULTS:

회진은 60분에서 425분까지 이뤄졌으며, 병실에 있는 시간은 평균 33%정도였다.

The patient care rounds varied in duration from 60 to 425 minutes. Median duration of rounds within patient rooms was approximately 33% of total time (range approximately 20-50%). 

세 가지 패턴이 관찰되었다.

Three general time-motion rounding patterns were observed: 

• a first pattern that predominantly involved rounding in ward hallways and little time in patient rooms; 
• a second pattern that predominantly involved time in a ward conference room; and 
• a third balanced pattern characterized by equal proportions of time in patient rooms and in ward hallways.

그러나 회진 시간과 병실에 있는 시간 사이에는 상관관계는 없었음.

Discussion

In this pilot-study we used RTLS technology to observe the real-world patterns of movement of attending physicians on an internal medicine service during a mandatory once-weekly medical teaching team patient care rounding session endorsed as a walk-rounds format. The RTLS technology allowed us to map physician movement through time (i.e., a novel use of RTLS technology in the realm of medical education and study of work flow). Analysis was performed on rounding events varying from 60 to 425 minutes in length with a mean duration of 201 minutes. The median proportion of rounds conducted within patient rooms was 33%, and increased total round duration did not correlate with increased time within patient care rooms; findings consistent with previous literature [7,18,19,22]. This pilot study offers a preliminary description of physician time-motion patterns during walk-rounds that may be reflective of distinct rounding styles.

의사들은 다양한 회진 방법 중 가장 자신에게 잘 맞는 방법(임상교육, 의사소통, 환자검진이 잘 되는 방법)을 선택할 것이다. 그러나 병실/복도/교실수업 등 사이의 이상적인 비율에 대해서는 아직 알려진 바가 없다.

It seems logical that exposure to varied rounding methods throughout a career will lead physicians to adopt those patterns of movement that they feel best allow them to achieve the goals of walk-rounds – namely to enhance clinical education, communication, and physical examination skills through a tradition attributed to Osler [23]. Yet little is known about the optimal combination of patient room/bedside and hallway or classroom teaching during these highly valued rounds. Various authors have suggested methods to improve walk-rounding activities and previous examination of medical learners found that different rounding approaches impact workflow [24-28]. It is therefore possible that varying patterns of movement during walk-rounds also play a role in modulating their efficacy in terms of patient, learner, and attending physician satisfaction.

CONCLUSIONS:

Observation using RTLS technology identified distinct time-motion rounding patterns that hint at differing rounding styles across physicians. Future studies using this technology could examine how the division of time during walk-rounds impacts outcomes such as patient satisfaction, learner satisfaction, and physician workflow

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BMC Med Educ. 2014 Feb 25;14:37. doi: 10.1186/1472-6920-14-37.

A real-time locating system observes physician time-motion patterns during walk-rounds: a pilot study.

Ward DR, Ghali WA, Graham A, Lemaire JB1.

Author information

Abstract

BACKGROUND:

Walk-rounds, a common component of medical education, usually consist of a combination of teaching outside the patient room as well as in the presence of the patient, known as bedside teaching. The proportion of time dedicated to bedside teaching has been declining despite research demonstrating its benefits. Increasing complexities of patient care and perceived impediments to workflow are cited as reasons for this declining use. Research using real-time locating systems (RTLS) has been purported to improve workflow through monitoring of patients and equipment. We used RTLS technology to observe and track patterns of movement of attending physicians during a mandatory once-weekly medical teaching team patient care rounding session endorsed as a walk-rounds format.

METHODS:

During a project to assess the efficacy of RTLS technology to track equipment and patients in a clinical setting, we conducted a small-scale pilot study to observe attending physician walk-round patterns during a mandatory once-weekly team rounding session. A consecutive sample of attending physicians on the unit was targeted, eight agreed to participate. Data collected using the RTLS were pictorially represented as linked points overlaying a floor plan of the unit to represent each physician's motion through time. Visual analysis of time-motion was independently performed by two researchers and disagreement resolved through consensus. Rounding events were described as a sequence of approximate proportions of time engaged within or outside patient rooms.

RESULTS:

The patient care rounds varied in duration from 60 to 425 minutes. Median duration of rounds within patient rooms was approximately 33% of total time (range approximately 20-50%). Three general time-motion rounding patterns were observed: a first pattern that predominantly involved rounding in ward hallways and little time in patient rooms; a second pattern that predominantly involved time in a ward conference room; and a third balanced pattern characterized by equal proportions of time in patient rooms and in ward hallways.

CONCLUSIONS:

Observation using RTLS technology identified distinct time-motion rounding patterns that hint at differing rounding styles across physicians. Future studies using this technology could examine how the division of time during walk-rounds impacts outcomes such as patient satisfaction, learner satisfaction, and physician workflow.

PMID:

 

24568589

 

[PubMed - in process] 

PMCID:

 

PMC3974061

 

Free PMC Article