September 6, 2010

Destination: Bedside

The dedicated central work corridor at the Walnut Creek hospital, 1954.

Few care givers are more deserving of mention this week than the acute care nurse.

As anyone who has spent time in a modern hospital can tell you, the nurse is the linchpin of care delivery in a complex, sometimes frenzied and chaotic environment. Ask any hospital nurse what he needs in a typical shift and he likely will ask for more time bedside with patients. Nursing is a caring profession in desperate need of time for one-to-one communication between the nurse and the patient.

At Kaiser Permanente’s Sidney R. Garfield Health Care Innovation Center, a design lab that models and tests care delivery innovations, I recently learned of a study underway to increase the time that the care nurse has with the patient. I’ll say more about “Destination Bedside” in a moment.

To free the nurse for time with the patient is not a new problem in care delivery. Over fifty years ago San Francisco architect Clarence Mayhew and Kaiser Permanente's founding physician, Sidney R. Garfield, earned industry accolades for a hospital design that took-on this problem. “Efficiency Centers on the Corridor” published in The Modern Hospital, March 1954, covered the layout and design of the new Kaiser Foundation Hospital in Walnut Creek, California. What was the problem asked the writer in The Modern Hospital with the conventional designs of the era? “Simply stated . . . the patient’s charts, medicines . . . equipment and utilities which the nurse uses in her work are too far removed from the patient.

The design solution was a new work corridor for the exclusive use of the care providers in the Walnut Creek hospital. “The [dedicated] central corridor becomes work space, and the nurses’ station, utility equipment, drugs, x-rays . . . linens, charts and so on for each patient can be kept in this work space just behind the patient’s room.” It was estimated the dedicated corridor would save six out of every seven steps a nurse takes in a conventional design and would offer immediate proximities to the patient. Nurses themselves have validated the design saying that the corridor enhanced patient privacy and one-to-one communication between nurse and patient.

Time marches on. The advance of medical knowledge, patient information systems, and biomedical and robotic devices have added layers of complexity to an already complex environment.

A few years ago a 36-hospital, nation-wide, time and motion study of nurse activities in acute care hospital settings was funded by the Robert Wood Johnson Foundation and the Gordon & Betty Moore Foundation. Ascension Health of St. Louis, Missouri, Kaiser Foundation Hospitals, Duke University Health System, New York-Presbyterian (the University Hospital of Columbia and Cornell universities), Vanderbilt University, Inova Health System, Carolinas Health System, and Intermountain Health, participated in the study.  Findings were reported in The Permanente Journal.

What emerged from the time and motion study was a picture of the hospital nurse “who is constantly moving from patient room to room, nurse station to supply closet and back to room, spending a minority of time on [direct] patient care . . . and a greater amount of time on documentation, the coordination of care [services], medication administration, and movement around the unit.”

In a typical 10-hour shift, the authors found that less than one fifth of nurse time was given to direct patient care. Thirty-five percent of nurse time was given to care documentation, 21 percent of time to care coordination, 17 percent of time in medication administration, and 7 percent of time was given to patient assessment and vital signs. Only 19 percent of the time in a 10-hour shift was devoted to patient bedside activities.

Which brings me back around to the study I heard about at the Garfield Center. "Destination Bedside" design engineers are seeking solutions that minimize chaotic disruptions to nurse care and others that enable the nurse to spend less time charting, arranging for care services, or hunting for equipment, and more time in direct patient care activities. The integrated suite of process changes, some hi tech and some not, include among other things, an efficient transfer of patient information at bedside during nurse shift changes. They include a medication administration program that reduces interruptions to improve patient safety. They employ wireless hand held devices that free the nurse from the nurse station to move bedside with care documentation. They also improve upon the deployment of equipment and supplies.

Pilot implementations are in progress at Kaiser Foundation hospitals with nurse time in patient rooms up 19.6 percent at two pilot locations.

This week we acknowledge the complexity that confronts the hospital care nurse and commend Kaiser Permanente for it's commitment to free-up time for the nurse to do what nurses feel called to do: care for their patients.