Vol. 10 Issue 11 Page 23
Time to Spare
Technology to streamline med administration adds 30 minutes for patient care
As bed units grow in footprint owing to a larger proportion of private rooms, larger rooms and larger unit size distances traveled and time spent by nursing staff in clinical and nonclinical activities have similarly increased.
What will it take to reduce nurses’ walking distance by 576 feet during a typical shift, thereby increasing time at bedside by 30 minutes? The question may seem trivial. However, for caregivers on inpatient units and their managers, 500-plus fewer feet to walk and 30 more minutes with patients could mean a significant improvement in patient care.
Nurses’ working conditions have gained prominence over the past few decades, partly due to mounting evidence suggesting significant associations with patient outcomes including medical errors, length of stay and mortality. Nurse-to-patient ratio, length of shifts, compensation, autonomy, rapport with physicians and other factors have been shown to impact job satisfaction and patient outcomes.
“Nurse-to-patient ratio has attracted considerable attention not only because of the association between nurse-to-patient ratio and patient outcomes, but also due to a rising awareness about demographic changes that includes an increasingly aging population, rising acuity levels, and a gradual shift in treatment demand from episodic illnesses to chronic illnesses,” said Tom Harvey, AIA, FACHA, principal with HKS Architects. “While evolving trends demand low nurse-to-patient ratios, workforce shortages and an upward trend in nurses’ age (mean age at 47 years) are posing a major challenge to address the issue.
“A key concern is the impact of these developments on direct-care time,” he continued. “Direct-care time is frequently portrayed as the victim of systemic factors and workforce trends. The prevalent low duration of direct-care time is frequently underscored in literature, with studies showing a considerable portion of nurses’ time spent on nonclinical services including hunting and gathering activities.”
As bed units grow in footprintowing to a larger proportion of private rooms, larger rooms and larger unit sizedistances traveled and time spent by nursing staff in clinical and nonclinical activities have similarly increased. A recent Shepley/Davies study found nurses walk an average distance of 3.89 miles per shift in a general care unit and 5.13 miles in an ICU.
Georgia Institute of Technology, working with HKS Architects and Houston Medical Center, Warner Robins, GA, conducted a study measuring the time nurses spent on medication-related activities. They predicted decentralized medication storage, specifically through nurse servers, would reduce walking distances and increase patient care time.
It is standard industry practice to store patient medications in a medication room on inpatient units. Medications are stored in automated medication dispensers (AMDs) – the ATMs of the pharmaceutical world.
Nurses make several trips to the medication room safe practice demands retrieving medications for different patients separately depending on the number of patients assigned to them.
“With unit footprints increasing in size, the trip to the medication room could constitute a long, time-consuming, and stressful process,” said Bob Farrow, AIA, LEED AP, principal with HKS. “Moreover, walking to the medication room is only one of numerous other trips nurses make as part of the care delivery process, including trips for supplies, equipments, linens and patient charts.”
A design solution to reducing nurse walking distance would bring the supplies and medications closer to them. Some inpatient units incorporate supply cabinets on the corridors to be shared between two or more rooms.
Another solution is providing nurse servers. Nurse servers are cabinets on the corridor walls of patient rooms, typically with a door from the corridor and another from the room’s interior. Supplies are delivered to the nurse server. Caregivers access the supplies from inside the room.
“Nurse servers are designed to stock both supplies and medications,” Farrow said. “Although it appears to be a simple solution to the nurse walking problem, operational issues pertaining to inventory management, control, rotation and charge capture, and restocking responsibility pose challenges in decision-making. Moreover, supplies and medications are the responsibility of two separate departments in hospitals.”
To improve efficiencies within the Houston Medical Center’s surgical neuro/ortho unit, administrators looked at two options. The first option was creating one central medication room while the second included creating a number of decentralized nurse servers.
“We wanted to compare how one design performed compared to the other,” said Grady W. Philips III, chief operating officer with Houston Healthcare. “To access the two alternative scenarios, we commissioned a simulation study, working with a team of clinicians and management staff.”
The team used a process simulation tool as well as observations and on-site interviews, to identify the many factors that affect nursing staff efficiency. Examples include daily average number of trips to the medication room and to nurse servers for medical and surgical patients, average time to access and transport medication, and average time to deliver medications to the patient.
According to Godfried Augenbroe, MSc, professor with Georgia Institute of Technology, different patient types, caregivers, and administrative personnel were arranged in locations according to a given logic in the simulation tool. “The interactions between them resulted in outcomes based on time and expense, allowing stakeholders to make informed decisions based on supporting data.”
The team considered the following key factors for the model:
- the time it took for nurses to administer medication to the patients;
- patient type and diagnosis; and
- walking distance to deliver the medication.
The model studied the number of feet the caregiver walked for every minute of care delivered. Since nursing trips related to a medical patient differ from those for a surgical patient, the variance in the number of trips to these two types of patients was coded into the simulation exercise.
To calculate the results, the nurses in the models were instructed to walk and deliver medications during 12-hour shifts. The nurses’ walking speed was assumed to be uniform and equal to 150 fpm (approximately 50 meters/minute), which is a conservative estimate for comfortable human walking speed. It is also the default value used by the simulation tool.
“Multiplying the average walking time by this number, we determined the distance walked in feet,” Augenbroe said. “The efficiency was calculated as the ratio of the distance walked per one minute of care delivered.”
The result of the simulation suggested nurse servers in patient rooms on average, reduced nurse walking by 576 feet over a 12-hour shift. The average predicted increase in direct care time was 30 minutes.
“Following the study, we implemented the model on our new medical tower to open in the spring of 2009,” Philips said. “It is a hybrid that includes the strategic placement of routine, non-packaged medicines in the patient room’s nurse server in conjunction with bedside medication verification.”
Further Discussions Necessary
Generally, nurse work conditions have been treated as an operational issue and addressed through operational interventions. The physical designs of the environments nurses work in are not considered as instrumental in affecting positive changes in working conditions and efficiencies.
“The simulation exercise demonstrated that facility design and operations interact constantly in providing the nursing work environment, and the physical design could play a major role in addressing operational issues,” Philips said. “It also allowed us to review the bottom line including speed, accuracy, and quality of care (defined by the amount of interaction time spent between nurse and patient and family).
“While 30 minutes may seem trivial, it could potentially save lives that would otherwise have been lost as nurses spend their time hunting for supplies and medication,” he added.
Clarissa Lima is an intern architect at Howell Rusk Dodson Architects in Atlanta and a former graduate research assistant at Georgia Institute of Technology, Atlanta. Debajyoti Pati is director of research at HKS Architects, Dallas.