As crowding in the emergency department (ED) becomes more widespread, there is concern that physicians may be pushed to increase clinical productivity at the expense of other activities, including teaching. Time and motion methodology applied to the ED setting is recent and has focused on understanding length of stay, communication patterns, and interruptions. We performed an observational, time-motion study in the ED of Grady Memorial Hospital using electronic data capture in order to study attending physician work flow patterns. We aimed to categorize physician tasks for the purpose of gaining a deeper understanding of work flow in order to improve efficiency. Our statistical analysis evaluated several teaching-focused questions including whether teaching led to less time spent in other areas (eg, electronic medical record (EMR), walking, and communication). Additionally, we evaluated whether interruptions affect time spent teaching. In this prospective, observational cohort study, trained research assistants shadowed physicians and recorded tasks in sub-minute intervals in three clinical zones of an urban level I trauma center: triage and supervision in a low-acuity area; a high-acuity medical area; and a trauma area. Quetech Workstudy + tablet-based software was used for data collection with the ability to record tasks of short duration (< 10 seconds). Task categories were prospectively defined and included direct patient care, EMR use, teaching, communication, walking, and waiting. Task details included interaction type, type of human contact, role of contacted staff, and patient identification. An interrater analysis was performed to ensure quality and consistency of data collected by six observers. A univariate regression analysis was used to determine the relationship between teaching and other activities. This research was funded by the Emory Medical Care Foundation. A total of 700 hours of observational data were collected for 52 faculty members, for a total of 62000 data points. A 1-minute increase in attending EMR resulted in a 0.85% decrease in the physician’s time spent teaching (p=0.02). Each additional minute of communication time was associated with a 2.38% increase in teaching time (p<0.0001). A 1-minute increase in uninterrupted communication time resulted in a 1.04% increase in teaching time (p<0.001), while a 1-minute increase in interrupted communication time corresponded to a 3.83% increase in teaching time (p<0.0001). Each minute spent walking resulted in a 4.34% increase in teaching time (p=0.01). As expected, there is a tradeoff between time spent using EMR and teaching. As communication time increased, we expected an increase in teaching time since these communication types included teaching. We were surprised, however, that interrupted communication time was associated with a greater increase in teaching time compared to uninterrupted communication. It is possible that more fragmented work flow may lead to more teaching opportunities. The positive association between walking and teaching time is surprising, leading to the hypotheses that attending physicians who are more physically active during shifts also engage more in teaching, or that walking serves as a segue to a teaching moment. These results help us gain a better understanding of the ways in which teaching can be effectively incorporated into ED work flow.
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