Effects of a Designated Note Writing Hour on Pediatric Intern Adherence to Duty Hours

Abstract

Objectives

Interns spend an inordinate amount of the workday writing notes, leading to less time in direct patient care. Since the introduction of the 80-h workweek, it has been shown that interns spend 12% of the workday in direct patient care, compared to 40% at the computer. A dedicated note-writing hour was introduced into the pediatric intern shift to evaluate its effects on note writing behaviors. Within 1 year of implementation in July 2019, we aimed to establish that 80% of all pediatric intern notes were completed prior to the end of their shift.

Methods

Time stamps from EPIC electronic health record (EHR) database were reviewed for all notes written by pediatric interns during three periods of interest: prior to the implementation of the hour (Jan-May 2019), immediately after implementation (July-Nov 2019), and a year after (May-Aug 2020).

Results

Prior to implementation, 67.9% of notes were completed by sign out. In the period immediately following implementation, and at a year post implementation, percentages increased to 72.5% and 73.5%, respectively. The percentage of notes completed prior to the end of the protected hour improved from 34.0% to 49.5% and 53.7%, respectively. The percentage of notes completed in less than 1 h also increased from 13.9% to 50.6% and 24.9%, respectively.

Conclusion

These results indicate that a designated note writing hour for interns offer an effective intervention to improve note writing efficiency, however, the goal of 80% note completion by sign out was not met.

Introduction

Since the introduction of the 80-h duty limit requirements in 2003, and their revision in 2011, ¹ residents have struggled to balance their time appropriately across their myriad of responsibilities. The literature has shown numerous benefits to resident work hours. One meta-analysis showed that both patient mortality and resident well-being had improved. ² The effects on patient mortality over this period are likely multifactorial and difficult to draw causality from. However, improved resident well-being was tied to more residents having babies, ³ greater ability to attend family events, ⁴ and less perceived stress. ⁵ The work-hour policy has also been showed to be associated with significant reductions resident-physician reported medical errors, including a 63% reduced risk of reported medical errors resulting in patient death. ⁶ Another study showed that medical errors are more impacted by resident reported work-stress (a composite of fatigue, excessive workload, distractions, stress, and inadequate time), rather than simply working over 80 h a week. ⁷ With this context in mind, we were interested in examining ways to simplify resident work loads within the confines of duty-hours.

Several studies have examined how residents spend their time within the 80-h work week. Two observational studies from 2012 and 2013 found that internal medicine interns only spent 12% of their time in direct patient care.^8,9 Both studies also found that the largest portion of intern time (∼40%) was spent at the computer. This trend was supported by a survey stating that over 67% of residents reported spending >4 h per day on documentation alone. ¹⁰ A 2016 time and motion study found residents to be spending 50.6% of their shifts at the computer, making it clear that the trend is ongoing. ¹¹

The electronic health record (EHR) is a powerful and essential tool in modern clinical practice, but it is undeniably time consuming. Also undeniable is the learning curve that comes with using EHR. There is a wide variability in EHR training in medical school. A multi-center study from 2017 found that only 62% of medical schools allowed students to write their own notes using EHR. ¹² This leads to interns that feel unprepared and unable to use EHR to its full potential under existing time restraints. ¹³ This burden is one more stressor in the life on an intern. When Chen, et al tracked Internal Medicine residents throughout the year, the time interns spend on note writing significantly decreased from July to October to January. ¹⁴ Additionally, it has been found that senior residents spend an average of 1.5 fewer hours on the computer per day when compared to interns. ¹⁵ This gap could be reflective of the shifting responsibilities of senior residents, who typically have fewer note writing responsibilities versus higher efficiency in performing the note writing tasks. Based on previous informal discussions and routine programmatic evaluations, we noted that one of the major cause of interns having to stay late, past time of sign-out, was to complete daily notes.

The literature shows difficulties faced by residency programs trying to achieve balance between patient care, education, and documentation in the face of the 80-h work week. The difficulty in adapting to EHR and note writing is an identified area for improvement. There is currently a lack of literature available on potential interventions to facilitate the transition from medical student to physician for the interns and alleviate some of the difficulties of timely completion of notes.

To explore quality improvement solutions, multiple meetings held with all the residents, program director, assistant program director and chiefs to assess what could be influencing the duty hour violations for the interns. One of the primary drivers that was identified by both the interns and seniors was the time it took to complete daily notes. This was the reason intervention was undertaken as part of the PDSA (Plan Do Study Act) cycle. ¹⁶ One of the secondary drivers identified was the multiple interruptions to the note writing, and the challenge the interns faced in trying to multi-task to write notes and perform clinical responsibilities. This is why the note writing hour was made “protected” when it was introduced (Figure 1).

Figure 1.

Driver diagram.

After performing this driver analysis, the goal of this quality improvement study was to decrease duty hour violations, which were previously identified to be largely a result of prolonged duration of time spent on note writing. As a proxy for duty hour overages, percentage of notes completed by the end of shift was used, as a burden of notes completed after sign-out would be indicative of a prolonged workday. The intervention included providing pediatric interns at a university hospital with a designated note-writing hour in the middle of their shifts with no clinical responsibilities during that time. The aim was to have 80% of all pediatric intern progress, transfer, and discharge notes completed prior to the end of their shifts within one year of implementation of the designated note writing hour, thus decreasing duty hour overages.

Methods

This quality improvement project took place in a pediatric residency program with 10 residents per year, at the 630 bed, Cooper University Hospital in Camden, NJ. Residents are trained only at this site, with elective rotations potentially being completed at an affiliated, stand-alone Children's Hospital. During a typical month there are 3–4 interns, 1–2 senior residents, and 1–2 sub-interns taking care of the patients on the inpatient unit. There are no fellows on the unit. EHR data was obtained via EPIC software from the hospital's Department of Information and Technology. Specifically requested data points were time stamps for when progress, transfer, and discharge notes were started, and when these notes were completed and signed by the interns.

A designated note-writing hour was introduced into the middle of the pediatric intern shift that was being performed on the pediatric inpatient unit beginning in July 2019 at this particular site. It was not introduced in out-patient clinic, on elective rotations, or in the intensive care units. This hour was scheduled from 1315 to 1415 h and occurred after the completion of noon conferences that ended at 1300. During this hour, pediatric interns (n = 20) were instructed to spend their time completing notes on EHR, while they were excused from other clinical and educational duties. Pagers/cisco phones were handed off to the senior residents during this period, who would respond to any pages or calls from the floor. A workroom is available and located separate from the clinical area of the pediatric inpatient unit, and was typically used by the Interns and senior residents during the note-writing period before and during the intervention. During the intervention, interns were encouraged to stay in that room for the duration of the hour or until all the notes were complete, whichever occurred first. Hospitalist attending physicians oversaw the education of residents on the inpatient unit and were asked to respect the protected time, and to consult the senior resident regarding any clinical responsibilities during that hour. Senior residents typically write notes for patients that are cared for by the sub-interns, and therefore only write those notes and infrequent admissions or discharge notes when the interns reach a pre-specified cap. Therefore, seniors have more time to assist with other clinical tasks and were able to fully take over the intern responsibilities during the note-writing hour.

Note writing data was analyzed for three time periods. The first period was 5 months prior to the introduction of the designated note-writing hour, from January to May 2019. The second period was immediately after the intervention implementation and after a wash-out period, from July to November 2019. The third period was from May to August 2020. This final period was after the protected hour had been in place for almost a full year for the 2019–2020 intern class (n = 10) and included some interns from the 2020 to 2021 class. This was a different set of interns and occurred during the COVID 19 pandemic.

Primary outcomes examined included: average note writing time, percentage of notes completed in less than 1 h, percentage of notes completed prior to sign out at 1800 h, and percentage of notes completed within the protected note writing hour, by 1415 h. Note writing time was determined by subtracting the time stamp from when the note was begun from the time stamp when the note was signed by the resident and was not influenced by addendums written after the completion, or timing of attending physician signatures. Note types were restricted to progress notes, transfer notes, and discharge summaries. All notes that were completed in less than 5 min were excluded from the analyses with the assumption that either the time stamp or the note was erroneous.

The study was conducted using the Plan-Do-Study-Act (PDSA) cycle method (see below).

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This quality improvement project was reviewed by the Cooper Research Institute regulatory body and was determined to not necessitate review by the Institutional Review Board. This quality improvement project was implemented with the knowledge of all the residents, supervising pediatric attendings, and staff nurses. Consents from study subjects (residents) were not required due to the quality improvement nature of the project. This study was presented to and approved by the quality improvement committee and the requirement for informed consent waved.

Results

During the pre-implementation period (Era 1), from January to May 2019, a total of 686 notes were analyzed. The designated note writing hour was introduced at the beginning of July 2019. From July to November 2019 was the immediate post implementation period (Era 2), during which 91 notes were analyzed. A third period was examined from May to August 2020 (Era 3), during which 313 notes were analyzed.

Prior to the introduction of the dedicated note writing hour (Era 1), 13.9% of pediatric intern notes were completed in less than 1 h. In the Era 2 period, immediately following implementation, that percentage showed a significant increase to 50.6% (p < 0.0001; Table 1; Figure 2). In the period observed almost a year post implementation (Era 3), that percentage decreased to 24.9%, which is a significant improvement from the Era 1 period (p < 0.0001).

Table 1.

Percentage of notes completed by pediatric interns across three eras, before and after the implementation of a designated note writing hour

	Frequency (Percentage)			p-values
Outcome	Era 1	Era 2	Era 3	Era 1 v. Era 2	Era 1 v. Era 3	Era 2 v. Era 3
Notes <1 h	95 (13.9%)	46 (50.6%)	78 (24.9%)	<0.0001	<0.0001	<0.0001
Total Notes	686	91	313
	Frequency (Percentage)			p-values
Outcome	Era 1	Era 2	Era 3	Era 1 v. Era 2	Era 1 v. Era 3	Era 2 v. Era 3
Finished Prior to End of Hour	233 (34.0%)	45 (49.5%)	168 (53.7%)	0.004	<0.0001	0.48
Total Notes	686	91	313
	Frequency (Percentage)			p-values
Outcome	Era 1	Era 2	Era 3	Era 1 v. Era 2	Era 1 v. Era 3	Era 2 v. Era 3
Notes Finished Prior to Sign Out	466 (67.9%)	66 (72.5%)	230 (73.5%)	0.38	0.08	0.86
Total Notes	686	91	313

Figure 2.

This graph shows the percentages of pediatric intern notes completed across the three experimental eras, segregated by specific outcome. The first outcome shows the percentage of notes completed in less than one hour. The next outcome shows the percentages of notes completed prior to the end of the protected note writing hour. The third and primary outcome shows the percentage of notes completed at the time of intern sign out. Era 1 occurred prior to implementation of the protected hour, Era 2 occurred immediately after, and Era 3 occurred one year after.

To analyze adherence to the protected note writing hour, the percentage of notes completed prior to the 1415 was measured. In the pre-note writing hour period (Era 1), only 34% of pediatric intern notes were completed prior to 1415. Immediately following the implementation of the hour (Era 2), that percentage increased to 49.5% (p = 0.004). This percentage remained elevated in Era 3, which showed 53.7% of pediatric intern notes being completed prior to the end of the designated note writing hour.

In Era 1, pediatric interns had been finishing 67.9% of their documentation prior to sign out at 1800 h. Immediately following the implementation of the designated note writing hour (Era 2), that percentage showed a slight increase to 72.5% (p = 0.38). When examined almost a year post implementation (Era 3), that percentage stayed steady at 73.5% (p = 0.86).

Discussion

Our quality improvement project was carried out according to the PDSA model. We planned to test whether providing pediatric interns with a mid-shift, designated note writing hour would help to curb time spent on documentation and duty hour overages. To test the effectiveness, this protected hour was introduced to the schedule of pediatric interns and various metrics were assessed before and after implementation.

The primary outcome evaluated whether this quality improvement initiative can decrease duty hour overages by examining percentage of notes completed by end of work shift. If a higher percentage of notes are finished prior to intern sign out, that would be indicative of less work being completed outside of scheduled work hours. Prior research has highlighted the difficulties that interns face in dividing their time between direct patient care and other responsibilities while adhering to duty hour limits.^8,9 It has also been shown that documentation engulfs a major percentage of intern time. ¹⁰ Despite this knowledge, a review of the literature found no prior attempts to reduce duty hour violations by targeting intern note writing behaviors. In our project, we looked at three points in time to evaluate how protecting an hour of intern time for documentation may affect the percentage of intern notes completed by sign out, to our knowledge a novel experiment. Our analysis demonstrated that the implementation of a protected note writing hour for interns increased the percentage of intern notes completed by sign out to 72.5% immediately and 73.5% after one year. This has not been done previously in other programs. While these improvements of roughly 5% were not statistically significant, we believe such impact could be meaningful in practice for residency programs that are struggling to complete documentation before sign out. Depending on the baseline performance at a program, this improvement could potentially be the difference between being cited by the ACGME for duty hour violations, or not.

Our secondary outcomes were analyses of documentation efficiency and whether the protected hour was being appropriately used by interns once implemented. The literature suggests that EHR training in medical school is inconsistent across institutions, causing many interns to feel unprepared for the documentation burden the job entails.^12,13 A link has been established, however, between an improvement in documentation efficiency with time and experience. ¹⁴ To our knowledge, no prior quality improvement projects have attempted to improve the documentation efficiency of interns. By blocking off protected note writing time for interns, we were able to demonstrate significant improvements in the percentage of notes completed in less than one hour, representing enhanced documentation efficiency of interns. The significant increase in the percentage of notes completed prior to the end of the protected hour show that the hour was indeed being used appropriately. However, it remains unclear how much of the improvement in efficiency is attributable to the protected hour versus natural improvements gained with experience.

Due to the study design and the number of participants being limited by residency size, sample size calculations were not performed. Other limitations of this quality improvement project reflect the variance in hospital medicine. While the same note types were selected for, there were significant differences in the number of notes analyzed across eras. This variation is potentially related to the decrease in pediatric hospitalizations during the COVID 19 pandemic, during which Era 3 took place. ¹⁷ There was also potential for variation in the way senior residents and attendings respected the protection of the hour. While the same instructions were given to all parties, no survey was performed to evaluate for week-to-week differences. Additionally, beyond the metric percentage of notes completed prior to the end of the note-writing hour, we do not have a good measure as to how compliant interns were in using the hour. Based on discussion with senior residents and attendings, the interns embraced this intervention and actively worked to complete their notes during the designated hour. However, we do not have concrete data regarding overall compliance by the interns with what they specifically did in the conference room during the note-writing hour.

Although all the phones were handed over from the interns to the seniors, we are not able to document whether the seniors performed the required clinical tasks that they were called about or relayed it verbally to the intern during the note-writing hour or after. This may have made the interns less likely to spend the whole time on note-writing if they were concerned with accumulation of clinical/patient care tasks during the hour.

There was also no evaluation on the quality of the notes before, and in each of the eras after the intervention. Anecdotally, there was no deterioration in the quality of the notes, however, this was not measured and is a possible limitation of this study.

Next steps for this project would be to evaluate how the protected note-writing hour affected the quality of intern notes and the influence of the protected hour on completion of clinical tasks. It would also be valuable to determine whether this intervention can be maintained, and residents and staff may be more compliant in an era that is not changed by COVID protocols. Since we used percentage of notes completed by sign out as a proxy for duty hour overages, looking directly at violation data across eras would be beneficial as well. While our study focused on time, other metrics may be more integral to physician well-being and patient safety.

Conclusion

In this quality improvement project, we found that providing pediatric interns with a protected hour for note-writing in the middle of their shifts may provide residency programs with a novel option to improve documentation practices. Utilization of the protected hour led to an increase in the percentage of notes completed by sign out and the percentage of notes completed in under one hour. In the era of the 80 h work week, more timely completion of documentation is imperative for reducing duty-hour violations.