Intern and Resident Workflow Patterns on Pediatric Inpatient Units: A Multicenter Time-Motion Study | Medical Education and Training | JAMA Pediatrics | JAMA Network
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Research Letter
December 2015

Intern and Resident Workflow Patterns on Pediatric Inpatient Units: A Multicenter Time-Motion Study

Author Affiliations
  • 1Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 2Division of Pediatric Hospital Medicine, Department of Pediatrics, Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Stanford, California
  • 3Center for Patient Safety Research, Division of General Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Pediatr. 2015;169(12):1175-1177. doi:10.1001/jamapediatrics.2015.2471

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).

Figure.  Activity Distribution by Category, Interns and Residents Combined (Percentage of Time per 24 Hours)
Activity Distribution by Category, Interns and Residents Combined (Percentage of Time per 24 Hours)

Major activity categories included subactivities as follows: waiting for something to respond or arrive (computer, paper, patient, telephone), looking for items or people (colleague, consultant, nurse, patient, supplies, telephone, computer, or patient medical record information), paper-write (writing notes on the printed handoff document; handwritten patient notes, orders, or prescriptions), paper-read (reviewing printed handoff document or part of patient record printed on paper, reading reference materials), education (formal education such as grand rounds or didactic lectures, informal medical education such as learning about a disease process during patient rounds, or patient service learning such as learning how to order a test in the electronic medical record, teaching medical students or residents medical information or patient service activities), telephone (answering or reading pager, paging colleague, getting results, scheduling a test/appointment, telephone call with patient/family members, physicians, nurses, medical students, other staff, or personal telephone calls), patient/family contact (taking patient history, casual conversation, physical examination, explaining the plan of care, educating patient, obtaining consent, discussing advance directives, or conducting medical procedures), personal (eating, sleeping, idle, walking, restroom, talking, personal texting/mobile telephone use, in call room, or donning contact precautions), computer-write (typing into the handoff document, email, sending a text page, writing patient notes, discharge summaries, orders, prescriptions, or incident reports), computer-read (reviewing computerized sign-out, patient record, electrocardiograms, chest radiography, or other patient information; reading email, reference articles, or other online reference material), and interprofessional communication (giving or receiving sign-out; listening to patient presentations or communicating with nurses, medical students, physicians, other staff, or multiple people).

Table.  Activity Distribution Comparison by Trainee Level and Shift Properties (Percentage of Time per 24 Hours)
Activity Distribution Comparison by Trainee Level and Shift Properties (Percentage of Time per 24 Hours)


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.

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Article Information

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 (

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.

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