Duration Of Rounds Research Articles

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

BackgroundWalk-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.MethodsDuring 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.ResultsThe 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.ConclusionsObservation 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.

Attending Rounds in the Current Era

General medicine rounds by attending physicians provide the foundation for patient care and education in teaching hospitals. However, the detailed activities of these rounds in the current era are not well characterized. To describe the characteristics of attending rounds for internal medicine inpatients in a large teaching hospital system. A cross-sectional observational study of attending rounds in internal medicine. Rounds were observed directly by research assistants. Four teaching hospitals associated with a large public medical school. Fifty-six attending physicians and 279 trainees treating 807 general medicine inpatients. Duration and location of rounds, composition of teams, and frequency of 19 potential activities during rounds. We observed 90 days of rounds. A typical rounding day consisted of 1 attending with 3 trainees visiting a median of 9 (range, 2-18 [SD, 2.9]) patients for a median of 2.0 hours (range, 25-241 [SD, 2.7] minutes). On rounds, teams most frequently discussed the patient care plan (96.7% of patients), reviewed diagnostic studies (90.7%), communicated with patients (73.4%), and discussed the medication list (68.8%). Teams infrequently discussed invasive lines or tubes (9.3%) or nursing notes (6.2%) and rarely communicated with nurses (12.0%) or taught physical examination skills (14.6%), evidence-based medicine topics (7.2%), or learner-identified topics (3.2%). Many commonly performed activities occurred infrequently at the bedside. Most activities on attending rounds do not take place at the bedside. The teams discuss patient care plans and test results most of the time but fail to include many items that may be of significant value, including specific aspects of patient care, interprofessional communication, and learner-centered education. Future studies are needed to further assess the implications of these observations.

Identifying dynamic tuberculosis case-finding policies for HIV/TB coepidemics

The global tuberculosis (TB) control plan has historically emphasized passive case finding (PCF) as the most practical approach for identifying TB suspects in high burden settings. The success of this approach in controlling TB depends on infectious individuals recognizing their symptoms and voluntarily seeking diagnosis rapidly enough to reduce onward transmission. It now appears, at least in some settings, that more intensified case-finding (ICF) approaches may be needed to control TB transmission; these more aggressive approaches for detecting as-yet undiagnosed cases obviously require additional resources to implement. Given that TB control programs are resource constrained and that the incremental yield of ICF is expected to wane over time as the pool of undiagnosed cases is depleted, a tool that can help policymakers to identify when to implement or suspend an ICF intervention would be valuable. In this article, we propose dynamic case-finding policies that allow policymakers to use existing observations about the epidemic and resource availability to determine when to switch between PCF and ICF to efficiently use resources to optimize population health. Using mathematical models of TB/HIV coepidemics, we show that dynamic policies strictly dominate static policies that prespecify a frequency and duration of rounds of ICF. We also find that the use of a diagnostic tool with better sensitivity for detecting smear-negative cases (e.g., Xpert MTB/RIF) further improves the incremental benefit of these dynamic case-finding policies.

Family-centered rounds in Pakistani pediatric intensive care settings: Non-randomized pre- and post-study design

BackgroundInvolvement of family in bedside rounds is one strategy to implement family-centered care to help families get clear information about their child, and be actively involved in decision-making about care. However in developing countries such as Pakistan, daily bedside rounds include the physician, residents, medical students and a nurse/technician. Parents are not currently a part of these rounds. ObjectiveTo assess whether family-centered rounds improve parents’ and health care professionals’ satisfaction, decrease patient length of stay, and improve time utilization when compared to traditional practice rounds in a population with a low literacy rate, socioeconomic status, and different cultural values and beliefs. DesignA non-randomized before–after study design. SettingA private hospital in Karachi, Pakistan. ParticipantsA convenience sample of 82 parents, whose children were hospitalized for a minimum of 48h, and 25 health care professionals able to attend two consecutive rounds. MethodsDuring the before phase, traditional bedside rounds were practiced; and during after phase, family-centered rounds were practiced. Parents and health care professionals completed a questionnaire on the second day of rounds. An observational form facilitated data collection on length of stay and time utilization during. ResultsParents’ ratings during the family-centered rounds were significantly higher for some parental satisfaction items: evidence of team work (p=0.007), use of simple language during the rounds (p=0.002), feeling of inclusion in discussion at rounds (p=0.03), decision making (p=0.01), and preference for family-centered rounds (p=<0.001). No significant differences were found in health care professionals’ satisfaction between rounds. Patient length of stay was significantly reduced in the family-centered rounds group, while no significant difference was found in the duration of rounds. Family-centered rounds served as an opportunity for parents to correct/add to patient history or documentation. ConclusionParents were satisfied with both forms of rounds; however, they appeared to have a greater preference for family-centered rounds than health care professionals. Family-centered rounds were a resource for Pakistani parents, enabling direct communication with the medical team without impacting on the time required to complete rounds. Family-centered rounds may improve quality of care such as decreasing length of stay or preventing critical incidents.

Fairness and Access Control for Mobile P2P Auctions over MANETs

Mobile ad hoc networks (MANETs) present similarities with Peer to Peer (P2P) systems in terms of decentralization, equality and autonomy. This results in the rise of new collaborative and spontaneous P2P applications over MANETs such as P2P auctions. The deployment of auctions over MANETS should provide new opportunities to the important marketplace created by mobile communities and may be a game changer in local markets when the mobile infrastructures are very pervasive. This business scenario implies multiple advantages such as ubiquity, availability, affordability, opportunity and spontaneity. Nevertheless, it faces various challenges such as fairness and security. In this paper we present a fully distributed architecture and a process designed to support P2P auctions over MANETs. The major goal of this paper is three-fold: i) to propose an estimation model of a fair round duration called Tfair (the bids collection duration) to fulfill fairness, ii) to propose a new scheme for access control and no replay that takes into consideration the unique constraints imposed by the crossing of MANETs, P2P and auctions, and iii) to validate the proposals by simulations. We prove the effectiveness of the proposed Tfair estimation model. We also show that the overhead of the proposed security solution is acceptable for the studied scenarios.

Solid waste management: case of collection and Vehicle Routing Problem in the city of Azemmour, Morocco

This paper considers a truck scheduling problem in the context of solid waste collection in the City of Azemmour. One such concern to city administrators is how to effectively distribute collection vehicles and crews in the region. The main object of this paper is to suggest a methodology for allocating trucks to the existing collection sites for minimizing cost and collecting 100% of waste. For this purpose, the software “Container Collector” was developed. This last is equipped with a file containing the application data that are required to represent the road network, the container position and the collection depot spatial information. In fact, the software allows determining routes which must be traversed in the city to optimize the vehicle routing. Thus, the software application has permit to determine four optimal routes which allow minimizing total distance traversed, total rounds duration and financial costs including salary, fuel and vehicle operation.

The learners' perspective on internal medicine ward rounds: a cross-sectional study

BackgroundWard rounds form an integral part of Internal Medicine teaching. This study aimed to determine the trainees' opinions regarding various aspects of their ward rounds, including how well they cover their learning needs, how they would like the rounds to be conducted, and differences of opinion between medical students and postgraduates.MethodsA cross-sectional study was conducted on a total of 134 trainees in Internal Medicine, comprising medical students, interns, residents and fellows, who were asked to fill in a structured, self-designed questionnaire. Most of the responses required a rating on a scale of 1-5 (1 being highly unsatisfactory and 5 being highly satisfactory).ResultsTeaching of clinical skills and bedside teaching received the lowest overall mean score (Mean ± SD 2.48 ± 1.02 and 2.49 ± 1.12 respectively). They were rated much lower by postgraduates as compared to students (p < 0.001). All respondents felt that management of patients was the aspect best covered by the current ward rounds (Mean ± SD 3.71 ± 0.72). For their desired ward rounds, management of patients received the highest score (Mean ± SD 4.64 ± 0.55), followed by bedside examinations (Mean ± SD 4.60 ± 0.61) and clinical skills teaching (Mean ± SD 4.50 ± 0.68). The postgraduates desired a lot more focus on communication skills, counselling and medical ethics as compared to students, whose primary focus was teaching of bedside examination and management. A majority of the respondents (87%) preferred bedside rounds over conference room rounds. Even though the duration of rounds was found to be adequate, a majority of the trainees (68%) felt there was a lack of individual attention during ward rounds.ConclusionsThis study highlights important areas where ward rounds need improvement in order to maximize their benefit to the learners. There is a need to modify the current state of ward rounds in order to address the needs and expectations of trainees.

The Return of Bedside Rounds: An Educational Intervention

Bedside rounds have decreased in frequency on teaching services. Perceived barriers toward bedside rounds are inefficiency and patient and house staff lack of preference for this mode of rounding. To evaluate the impact of a bedside rounding intervention on the frequency of bedside rounding, duration of patient encounters and rounding sessions, and patient and resident attitudes toward bedside rounds. A pre- and postintervention design, with a bedside rounding workshop midway through two consecutive internal medicine rotations, with daily resident interviews, patient surveys, and an end-of-the-year survey given to all Medicine house staff. Medicine house staff and medicine patients. Frequency of bedside rounds, duration of new patient encounters and rounding sessions, and patient and house staff attitudes regarding bedside rounds. Forty-four residents completed the bedside rounding workshop. Comparing the preintervention and postintervention phases, bedside rounds increased from <1% to 41% (p < 0.001). The average duration of walk rounding encounters was 16 min, and average duration of bedside rounding encounters was 15 min (p = 0.42). Duration of rounds was 95 and 98 min, respectively (p = 0.52). Patients receiving bedside rounds preferred bedside rounds (99% vs. 83%, p = 0.03) and perceived more time spent at the bedside by their team (p < 0.001). One hundred twelve house staff (71%) responded, with 73% reporting that bedside rounds are better for patient care. House staff performing bedside rounds were less likely to believe that bedside rounds were more educational (53% vs. 78%, p = 0.01). Bedside rounding increased after an educational intervention, and the time to complete bedside rounding encounters was similar to alternative forms of rounding. Patients preferred bedside rounds and perceived more time spent at the bedside when receiving bedside rounds. Medicine residents performing bedside rounds were less likely to believe bedside rounds were more educational, but all house staff valued the importance of bedside rounding for the delivery of patient care.

Secure and fair auctions over ad hoc networks

The emergence of new mobile and wireless networks, with novel capabilities, offers opportunities to widen traditional internet-based applications. In this paper, we focus on a famous and widely used e-commerce application: auctions, and propose their deployment over ad hoc networks. Actually, we specify here this auction model while assuring identified crucial requirements: security and fairness. Security services are provided through threshold cryptography mechanisms whereas fairness is provided through rounds duration calculation. We prove that such a novel mobile commerce application presents advantages with regard to conventional economic models. Evaluations present optimistic results promising a realisable deployment of our auction model.

Effect of the 80-hour workweek on resident burnout.

With the introduction of the newly mandated restrictions on resident work hours, we expected improvement in subjective feelings of personal accomplishment and lessened emotional exhaustion and depersonalization. Residents and faculty members completed an anonymous online Maslach Burnout Inventory Human Services Survey (3rd ed; Consulting Psychologist Press Inc, Palo Alto, Calif) and work-hour registry before and after implementation of new restrictions. Urban, university-based department of surgery. All house staff (n = 37) and faculty (n = 27). Introduction of new Institutional Standards for Resident Duty Hours 2003. Main Outcome Measure Resident work hours and levels of emotional exhaustion, perceived degree of depersonalization, and personal accomplishment. Resident work hours per week decreased from 100.7 to 82.6 (P < .05) with introduction of the new schedule. Home call and formal educational activity time within working hours (eg, clinical conferences) significantly (P < .05) decreased from 11.5 and 4.8 hours to 4.6 and 2.5 hours per week, respectively. Operating room hours, clinic time, and duration of rounds did not show a significant change. Changes in parameters of resident and faculty emotional exhaustion, depersonalization, and personal accomplishment did not show statistical significance (P > .05). Despite successful reductions in resident work hours, measures of burnout were not significantly affected. However, important clinical activities such as time spent in the operating room, clinic, and making rounds were maintained. Formal in-hospital education time was reduced.

Golf course revenue management: A study of tee time intervals

Golf courses have two strategic levers, round duration control and demand-based pricing, that they can deploy in a revenue management programme. Before embarking on a revenue management programme, golf courses must first clearly define their capacity. This study uses simulation to study the most controllable factor of capacity: the tee time interval. Intuitively, reducing the interval between parties will lead to an increase in revenue; however, this paper shows that interval reductions may actually lead to decreased revenue.Research in revenue management (RM) has previously addressed the theoretical and practical problems facing airlines and hotels, among other industries, but has given little attention to the golf course industry (Kimes, 1989; Weatherford and Bodily, 1992). The golf course business is similar enough to hotel and airline operations that golf courses should be able to apply RM principles (Kimes, 2000).Industries using RM generally measure their performance by calculating their revenue (or contribution) per available time-based inventory unit. For example, hotels calculate their revenue per available room-night (RevPAR), airlines determine their revenue per available seat-mile (RevPAS), and restaurants rely on revenue per available seat-hour (RevPASH). Based on this logic, golf courses should measure their revenue per available tee-time (RevPATT), but the definition of availability is not as precise as in other industries. The number of available tee times is affected by both controllable and uncontrollable factors. Controllable factors include the length of a round of golf, the dispatching rule used, maintenance and the tee time interval. Uncontrollable factors include the number of hours of daylight and weather. Unless golf course operators have a clear definition of their capacity, they will not be able to measure the performance of their RM systems.This paper focuses on the most easily controllable factor affecting course capacity: the tee time interval. A dynamic simulation model was developed, which can be used to quantify the trade-offs in determining an appropriate tee time interval. Intuitively, reducing the time interval between parties might lead to an increase in throughput and revenue; however, tee time interval reductions may amplify the effects of the variations in pace of play and result in a reduced RevPATT.

Attending rounds on in-patient units: differences between medical and non-medical services

The objective of this cross-sectional observational study was to quantify communication patterns between teachers and trainees on in-patient attending ward rounds and assess trainees' perceptions of the effectiveness of teaching interactions. Sixty-nine in-patient ward rounds on medical and non-medical teaching services at a university hospital and its affiliated VA Medical Center were studied. Teaching rounds were observed and audiotaped, and trained raters coded verbal interchange for its location, speaker identity and topic of the exchange. One to three days following the teaching rounds, residents and students were interviewed and completed a questionnaire concerning recollections of the content of the session. Medical rounds lasted a mean of 90 minutes, while non-medical rounds averaged 38 minutes. Medical teams spent more time than non-medical teams on case presentations and discussions of diseases not directly related to patient care. Both groups averaged approximately 10 minutes directly interacting with patients, and equal times were spent speaking by the teacher and trainees. The role of postgraduate year 1 residents and medical students primarily was to recite details of patients' clinical condition. Twenty-nine per cent of trainees were unable to recall a specific teaching point from rounds when interviewed 1-3 days later. Duration and content of in-patient rounds differed on medical and non-medical services. For both, discourse tended to be hierarchical, with those at different training levels adhering to specific roles. Bedside patient interactions were limited. The content recalled by students and house staff suggests that new, more effective educational paradigms are needed.

Bedside case presentations: why patients like them but learners don't.

To determine current attitudes of patients, medical students, housestaff, and clinical faculty toward bedside case presentations. Survey using multiple-choice questionnaire and open comments for students, housestaff, and faculty, and a structured interview of patients. Major teaching hospitals on the campus of a midwestern medical school, staffed by full-time faculty. 136 medical students, 58 housestaff, 66 faculty, and 73 patients. 85% of patients liked the case presentation discussion at the bedside, but 95% of both students and housestaff felt more comfortable with such discussion away from the patient. Attending faculty were about evenly divided in preference, with the younger staff preferring the conference room setting. Most patients (88%) opposed rounds in the hallway. Duration of rounds of one to two hours was felt desirable by most, but 50% of students preferred a duration of less than one hour. For length of new patient case presentation, 60% of learners again favored brevity, less than 5 minutes. Bedside rounds are an opportunity to sharpen diagnostic skills and to demonstrate the art of medicine. They are undervalued by learners and younger faculty but appreciated by patients. The authors recommend that faculty improve bedside rounds by assessing team members' educational needs, by cultivating sensitivity and respect for the needs of all parties, and by assuring pertinence and brevity of bedside discussion.