title: A Time-Motion Study of ICU Workflow and the Impact of Strain.
abstract: OBJECTIVE
  Understanding ICU workflow and how it is impacted by ICU strain is necessary for implementing effective improvements. This study aimed to quantify how ICU physicians spend time and to examine the impact of ICU strain on workflow.
  
  
  METHODS
  Prospective, observational time-motion study.
  
  
  METHODS
  Five ICUs in two hospitals at an academic medical center.
  
  
  METHODS
  Thirty attending and resident physicians.
  
  
  METHODS
  None.
  
  
  RESULTS
  In 137 hours of field observations, the most time-84 hours (62% of total observation time)-was spent on professional communication. Reviewing patient data and documentation occupied a combined 52 hours (38%), whereas direct patient care and education occupied 24 hours (17%) and 13 hours (9%), respectively. The most frequently used tool was the computer, used in tasks that occupied 51 hours (37%). Severity of illness of the ICU on day of observation was the only strain factor that significantly impacted work patterns. In a linear regression model, increase in average ICU Sequential Organ Failure Assessment was associated with more time spent on direct patient care (β = 4.3; 95% CI, 0.9-7.7) and education (β = 3.2; 95% CI, 0.7-5.8), and less time spent on documentation (β = -7.4; 95% CI, -11.6 to -3.2) and on tasks using the computer (β = -7.8; 95% CI, -14.1 to -1.6). These results were more pronounced with a combined strain score that took into account unit census and Sequential Organ Failure Assessment score. After accounting for ICU type (medical vs surgical) and staffing structure (resident staffed vs physician assistant staffed), results changed minimally.
  
  
  CONCLUSIONS
  Clinicians spend the bulk of their time in the ICU on professional communication and tasks involving computers. With the strain of high severity of illness and a full unit, clinicians reallocate time from documentation to patient care and education. Further efforts are needed to examine system-related aspects of care to understand the impact of workflow and strain on patient care.
authors.affiliation: 1Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY. 2Department of Medicine, Montefiore Medical Center, Bronx, NY. 3Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY.
authors.forename: Yosefa
authors.initials: Y
authors.lastname: Hefter
authors.forename: Purnema
authors.initials: P
authors.lastname: Madahar
authors.forename: Lewis A
authors.initials: LA
authors.lastname: Eisen
authors.forename: Michelle N
authors.initials: MN
authors.lastname: Gong
mesh_terms: D003142:Communication; D003201:Computers / Q000706:statistics & numerical data; D004282:Documentation / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration* / Q000706:statistics & numerical data*; D007400:Interprofessional Relations; D008297:Male; D005791:Patient Care / Q000706:statistics & numerical data; D010353:Patient Education as Topic / Q000706:statistics & numerical data; D010820:Physicians / Q000458:organization & administration* / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012720:Severity of Illness Index; D013997:Time Factors; D013996:Time and Motion Studies; D057188:Workflow