Intern and Resident Workflow Patterns on Pediatric Inpatient UnitsA Multicenter Time-Motion Study

As resident-physician work hours have decreased, and patient complexity¹ and hospital documentation² have concurrently increased, concerns have mounted about the time residents have available for education and face-to-face patient care. Single-center internal medicine studies have found that 12% of trainee time is spent with patients vs 40% in front of the computer.^3,4 To our knowledge, no multicenter studies have evaluated this issue in any specialty, including pediatrics. We sought to quantify the proportion of time spent by residents in direct care, indirect care activities, and education across 9 pediatric institutions.

We conducted time-motion observations on the pediatric wards of 9 hospitals. Institutional review board approval was granted by the coordinating center (Boston Children's Hospital; no data were collected at this site) and institutional review board approval was also obtained at all 9 data collection institutions. Activities were categorized using a physician task list previously adapted for pediatric inpatient use.^5,6 Time-motion observations were scheduled to occur on a representative ratio of hours from all 24 hours of the day, and weekday vs weekend days, divided between interns and supervising residents. During observations, research assistants followed a single intern or resident, recording start and stop times for activities using a time-motion database on a tablet-based Microsoft Access database of 12 major activity categories and 114 minor activities. To compare the percentage of time in activities between groups, we used a generalized estimating equation z test, accounting for clustering by observation session with a fixed effect for site, using a Dirichlet distribution (a statistical distribution for a continuous variable—in this case time—across multiple categories—in this case activities).

A total of 3452 hours of time-motion data were collected. Across all sites and levels of training, trainees spent more time in interprofessional communication (34.7%), and at the computer (20.5%), and less time in contact with patients and families (12.0%) and in educational activities (4.7%) (Figure). Residents spent more time than interns in interprofessional communication (38.3% vs 31.1%, P = .001) and less time in contact with patients and families (10.3% vs 13.7%, P < .001). During the night, less time was spent in interprofessional communication (29.5% vs 39.3%, P < .001) and education (1.5% vs 7.6%, P < .001) than during the day, with more time spent in contact with patients and families (13.8% vs 10.2%, P < .001). Less time was spent on the weekends in education (1.4% vs 6.2%, P < .001) and interprofessional communication (29.9% vs 36.7%, P = .007) (Table).

In 9 pediatric hospitals, residents spent a large proportion of time in interprofessional communication and at the computer, and relatively little time in direct patient care and education. Trainees working nights and weekends spent more time in direct care and interns spent more time than supervising residents. Time spent in education was particularly low on weekends and nights.

The time pediatric trainees spent at the bedside was similar to that reported in internal medicine studies, but our trainees spent less time at the computer.^3,4 Education time was less than found by Block et al³ (where nonbedside rounds was counted as education). We considered nonbedside rounds to be interprofessional communication except during moments when explicit teaching occurred.

Defining time allocation precisely is complex. For example, education and interprofessional communication may occur simultaneously during rounds, but time-motion analysis does not account well for multitasking, a limitation of our study. Additional limitations are the potential for a Hawthorne effect and that observations were restricted to the inpatient setting.

Overall, it is concerning that pediatric residents spend relatively little time at patients’ bedsides, despite the centrality of direct patient care to their training, as well as to families’ care experiences. Further, though residency has become more shift-based, education time at night remains disproportionately low. Increasing attention to resident activities throughout the day and night is needed to prioritize direct patient care and education.

Corresponding Author: Amy J. Starmer, MD, MPH, Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital/Harvard Medical School, 300 Longwood Ave, Boston, MA 02115 (amy.starmer@childrens.harvard.edu).

Published Online: October 26, 2015. doi:10.1001/jamapediatrics.2015.2471.

Author Contributions: Ms Yoon had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Starmer, Landrigan.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Starmer, Destino.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Yoon.

Obtained funding: Starmer, Landrigan.

Study supervision: Landrigan.

Conflict of Interest Disclosures: Dr Starmer reported receiving honoraria and travel reimbursement from multiple academic and professional organizations for delivering lectures on handoffs and patient safety. Dr Landrigan has served as a paid consultant to Virgin Pulse to help develop a Sleep and Health Program. He is supported in part by the Children’s Hospital Association for his work as an Executive Council member of the Pediatric Research in Inpatient Settings network. In addition, Dr Landrigan has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety and has served as an expert witness in cases regarding patient safety and sleep deprivation. No other disclosures were reported.

Funding/Support: This study involved the secondary analysis of data collected during the I-PASS (I, Illness severity; P, Patient summary; A, Action items; S, Situation awareness and contingency planning; S, Synthesis by receiver) Study, which was supported by grant R18AE000029 from the US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Additional funding for the I-PASS Study was provided by Oregon Comparative Effectiveness Research K12 Program, grant 1K12HS019456 from the Agency for Healthcare Research and Quality, Medical Research Foundation of Oregon, Physician Services Incorporated Foundation (of Ontario), and Pfizer (unrestricted medical education grant).

Role of the Funder/Sponsor: The sponsors of the study had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the federal government.

Additional Information: Members of the I-PASS Study Group include individuals from the following institutions: Boston Children’s Hospital (primary site): April D. Allen, MPA, MA (currently at Heller School for Social Policy and Management, Brandeis University), Elizabeth L. Noble, BA, Lisa L. Tse, BA. Boston Children’s Hospital/Harvard Medical School (primary site): Angela M. Feraco, MD, Christopher P. Landrigan, MD, MPH, Theodore C. Sectish, MD, Amy J. Starmer, MD, MPH. Benioff Children’s Hospital/University of California, San Francisco School of Medicine: Glenn Rosenbluth, MD, Daniel C. West, MD. Brigham and Women’s Hospital (Data Coordinating Center): Anuj K. Dalal, MD, FHM, Carol A. Keohane, MS, RN, Stuart Lipsitz, PhD, Jeffrey M. Rothschild, MD, MPH, Matt F. Wien, BS, Catherine S. Yoon, MS, Katherine R. Zigmont, BSN, RN. Cincinnati Children’s Hospital Medical Center/University of Cincinnati College of Medicine: Javier Gonzalez del Rey, MD, MEd, Jennifer K. O’Toole, MD, MEd, Lauren G. Solan, MD. Doernbecher Children’s Hospital/Oregon Health and Science University: Megan Aylor, MD, Amy J. Starmer, MD, MPH, Windy Stevenson, MD, Tamara Wagner, MD. Hospital for Sick Children/University of Toronto: Zia Bismilla, MD, FRCPC, MEd, Maitreya Coffey, MD, FRCPC, Sanjay Mahant, MD, MSc, FRCPC. Lucile Packard Children’s Hospital Stanford/Stanford University: Rebecca L. Blankenburg, MD, MPH, Lauren A. Destino, MD, Jennifer L. Everhart, MD, Madelyn Kahana, MD (currently at Albert Einstein College of Medicine), Shilpa J. Patel, MD (currently at Kapi’olani Medical Center for Women and Children/University of Hawai’i John A. Burns School of Medicine), Paul J. Sharek, MD, MPH. Primary Children’s Hospital/Intermountain Healthcare/University of Utah School of Medicine: James F. Bale Jr, MD, Jaime Blank Spackman, MSHS, CCRP, Rajendu Srivastava, MD, FRCPC, MPH, Adam Stevenson, MD. St Louis Children’s Hospital/Washington University School of Medicine: Kevin Barton, MD, Kathleen Berchelmann, MD, F. Sessions Cole, MD, Christine Hrach, MD, Kyle S. Schultz, MD, Michael P. Turmelle, MD, Andrew J. White, MD. St. Christopher’s Hospital for Children/Drexel University College of Medicine: Sharon Calaman, MD, Bronwyn D. Carlson, MD, Robert S. McGregor, MD (currently at Akron Children’s Hospital/Northeast Ohio Medical University), Vahideh Nilforoshan, MD, Nancy D. Spector, MD. Walter Reed National Military Medical Center/Uniformed Services University of the Health Sciences: Jennifer H. Hepps, MD, Joseph O. Lopreiato, MD, MPH, Clifton E. Yu, MD.