ANALYSIS OF THE WORKLOAD FOR THE RAPID RESPONSE

TEAM IN THE UNIVERSITY AND MOTT CHILDREN’S HOSPITALS

Final Report

The University of Michigan Health System The University Hospital, Nursing Department

C.S. Mott Children’s Hospital, Nursing Department Prepared for:

Jason Maynard, RN, Nurse Operations Manager Sam Clark, Senior Management Engineer of Program and Operations Analysis

Dr. Richard Coffey, Director of Program and Operations Analysis

Prepared by: Ana Ayau, Industrial and Operations Engineering (IOE) 481 Student

Michael Grondin, Industrial and Operations Engineering (IOE) 481 Student Joel Ramirez, Industrial and Operations Engineering (IOE) 481 Student

Timothy Schaetzel, Industrial and Operations Engineering (IOE) 481 Student

Prepared on: 12 December 2008

Page | i

Table of Contents

Executive Summary ......................................................................................................... iii Background ...................................................................................................................... iii Methodology ..................................................................................................................... iii Mott Findings ................................................................................................................... iv UH Findings ...................................................................................................................... iv Mott Conclusions ............................................................................................................. iv UH Conclusions ................................................................................................................. v Recommendations ............................................................................................................. v Introduction ....................................................................................................................... 1 Goals and Objectives ........................................................................................................ 1 Background ....................................................................................................................... 1 Project Plan ....................................................................................................................... 2 Key Issues .......................................................................................................................... 2 Project Scope ..................................................................................................................... 3 Expected Impact and Outcomes ...................................................................................... 3 Data Collection .................................................................................................................. 3 Receipt of Existing Data ..................................................................................................... 3 Interviews ............................................................................................................................ 4 Time Studies ........................................................................................................................ 4 Findings .............................................................................................................................. 5 Findings from Interviews .................................................................................................... 5 Nursing Administration ...................................................................................................... 5 Mott Personnel .................................................................................................................... 5 UH Personnel ...................................................................................................................... 6 Findings from Historical Data ........................................................................................... 6 Findings from Time Studies ............................................................................................... 7 Mott Time Studies .............................................................................................................. 8 UH Time Studies .............................................................................................................. 12 Conclusions ...................................................................................................................... 15 Mott Conclusions .............................................................................................................. 15 UH Conclusions ................................................................................................................ 17 Recommendations ........................................................................................................... 20 Mott Recommendations .................................................................................................... 20 UH Recommendations ...................................................................................................... 21 Acknowledgements ......................................................................................................... 22 Appendix A: Current UH RRT Time Log Examples .................................................... A Appendix B: PICU 7:00am to 7:00pm Log Sheet .......................................................... B Appendix C: PICU 7:00pm to 7:00am Log Sheet .......................................................... C Appendix D: Team Data Collection Sheet ...................................................................... D Appendix E: Modified Mott RRT AM Time Log .......................................................... E Appendix F: Modified Mott RRT PM Time Log ........................................................... F Appendix G: New UH RRT AM Time Log ................................................................... G Appendix H: New UH RRT PM Time Log.................................................................... H

Page | ii

List of Tables and Figures

Tables ................................................................................................................................... Distribution of Time Spent Collecting Data in Mott .......................................................... 5 Distribution of Time Spent Collecting Data in UH ............................................................ 5 Comparison of Funding and FTE Work Usage in Mott ................................................... 17 Comparison of Funding and FTE Work Usage in UH ..................................................... 19 Figures .................................................................................................................................. Number of RRT Calls and Dispatch Codes Per 1000 Discharges in Mott ......................... 7 Number of RRT Calls and Dispatch Codes Per 1000 Discharges in UH ........................... 7 Time Breakdown of the Major Activities in Mott for Historical and Observational Data . 8 Time Breakdown of RRT Core Category in Mott .............................................................. 9 Time Breakdown of PICU Support in Mott ...................................................................... 10 Time Breakdown of PICU Support - Other PICU Patient Care in Mott .......................... 11 Time Breakdown of Miscellaneous Activities in Mott ..................................................... 12 Time Breakdown of Major Activities in UH for Historical and Observational Data ....... 13 Time Breakdown of RRT Core Category in UH .............................................................. 13 Time Breakdown of SICU Support Category in UH ........................................................ 14 Time Breakdown of Miscellaneous Activities in UH ....................................................... 15 Historical RRT Core - Category Breakdown .................................................................... 19

Page | iii

Executive Summary The Nurse Operations Manager suspected that the University of Michigan Hospital (UH) and C.S. Mott Children’s Hospital (Mott) Rapid Response Team (RRT) nurses’ workload was imbalanced. The nature of the RRT programs creates large amounts of on-call down time during which the nurses are being funded. The Nurse Operations manager wanted to determine solutions to combat this non-value added on-call time but was unsure if the non-value added on-call time was accurately logged by the RRT nurses in UH. He also had no current or historical time log data from the Mott RRT program. The Nurse Operations Manager wanted to determine the respective Full Time Equivalent (FTE) allocation for the Mott and UH programs and explore alternatives to decrease wasted downtime. In order to make an informed decision, he wanted to validate the time log data in UH and learn the time log data regarding Mott. In addition, he wanted to know if there had been a quantifiable decrease in the number of dispatch codes since RRT was implemented. This report details the analysis of the workload for RRT nurses in UH and Mott. The Nurse Operations Manager asked a team of Industrial and Operations Engineering (IOE) 481 students (project team) to examine the economic efficiency and overall effectiveness of the nurses’ role on the RRT. This report contains the methods for evaluating the workload, findings, conclusions, and recommendations regarding the nursing workload. Background The Nurse Operations Manager provided the following background information: RRT is a preventative measure that responds to calls regarding patients exhibiting preliminary symptoms of cardiac or respiratory arrest. Ideally, this team takes preventative actions as soon as symptoms start occurring. The team consists of an Intensive Care Unit (ICU) nurse, a respiratory therapist (RT) and a physician. In Mott, the PICU Fellow and Hospitalist respond to every RRT call at the onset. In UH, the registered nurse (RN) and RT respond, briefly evaluate the patient, and either collaborate with the primary medical service or activate the RRT physician (either the Surgery Critical Care Fellow or a Hospitalist). The University of Michigan Hospital first implemented the RRT in UH in November of 2005 in units 6B and 6C. By July 24, 2007, the RRT covered all inpatient areas in both UH and Mott. The UH RRT is based in the Surgical ICU (SICU), and the Mott RRT is based in the Pediatric ICU (PICU). Currently, hospital administration has allocated 5.08 Full Time Equivalent (FTE) units for the UH RRT and 2.5 FTEs for Mott RRT outside the general nursing budget. Methodology

- Collection of Existing Log Data and Financial Data: o The Nurse Operations Manager provided the project team with existing UH log

data and all appropriate FTE allotment information. The PICU Nurse Manager provided the existing Mott log data.

Page | iv

- Interviews: o The project team interviewed the PICU and SICU Nurse Managers, the PICU

Clinical Nurse Specialist, and the SICU Clinical Nurse Supervisor. They provided the background knowledge of the RRT and their interpretation of the workload of the RRT.

o The project team also met with the Director of Finance for Nursing Administration and the Assistant to the Chief of Nursing to discuss budgeting and any high level management concerns about the project. Additionally, the project team met with the National Registry of Cardio Pulmonary Resuscitation (NRCPR) Database Coordinator to discuss statistical elements of the project.

- Time Studies: o The project team observed RRT nurses in approximately 4 hour increments in UH

and Mott. In total, there were 41 hours of data collected in UH and 40 hours collected in Mott. This observed data was compared to existing time logs to develop conclusions and recommendations.

Mott Findings After performing 40 hours of observations in Mott, the data revealed that RRT nurses spend 19% of their time performing core RRT work, 49% of their time assisting in the PICU, and 32% of their time completing miscellaneous tasks such as eating, hospital project work, and personal time. This amounts to 4.51 hours, 11.81 hours, and 7.68 hours per 24 hour day respectively. Dispatch code rates were not numerically affected after the implementation of RRT. UH Findings After performing over 41 hours of observation in UH, the data revealed that RRT nurses spend 48% of their time performing core RRT work, 16% of their time assisting in the SICU, and 36% of their time completing miscellaneous tasks similar to the ones mentioned in Mott. This amounts to 11.61 hours, 3.73 hours, and 8.67 hours per 24 hour day, respectively. Dispatch code rates were not numerically affected after the implementation of RRT. Mott Conclusions The differences between observed time data and historical time data for RRT core work, PICU support, and miscellaneous tasks were insignificant. This fact implies the previous logs kept by the nurses are accurate representations of the aforementioned categories of work. However, the information regarding the time breakdown for individual tasks within a category of work were not detailed enough to yield strong conclusions about the specific amounts of time allocated to each task. Also, the portion of PICU funding is appropriate since the amount of funding it pays matches the amount of time RRT nurses spend assisting in the unit. Large amounts of on-call time present opportunities to perform project work for the hospital. However, the only challenge to the project work opportunity is the 40 nurses in rotation for the RRT position. Under the current rotation model, there are not enough projects to assign to all RRT personnel. Finally, there has been no numerical effect on dispatch code rates since the implementation of the RRT.

Page | v

UH Conclusions The differences between observed time data and historical time data for RRT core work, SICU support, and miscellaneous tasks were insignificant. This fact implies the previous logs kept by the nurses are accurate representations of the aforementioned categories of work. However, the information regarding the time breakdown for individual tasks within a category of work was not detailed enough to yield strong conclusions about the specific amounts of time allocated to each task. The SICU is receiving assistance from the RRT nurse during the nurse’s down time and is not funding the program appropriately. Large amounts of on-call time present opportunities to perform project work for the hospital. However, the only challenge to this project work opportunity is the 35 nurses in rotation for the RRT position. Under the current rotation model, there are not enough projects to assign to all RRT personnel. Lastly, there has been no numerical effect on dispatch code rates since the implementation of the RRT. Recommendations Based on the conclusions about the RRT programs’ budget structure, the project team is recommending maintaining the current level of funding from the PICU for the Mott RRT and using funding from SICU for the amount of corresponding work done by the UH RRT nurse in the SICU. As well, management should investigate assigning both RRT programs project work for the general hospital so that the work the RRT programs perform benefits the department that provides much of their funding – Central Staffing. Additional recommendations include implementing a new log sheet for both RRT programs because the majority of tasks take approximately 30 minutes. To precisely measure the individual tasks each nurse completes in Mott, the proposed log sheet divides the time intervals on the current log sheet into 30 minute intervals instead of hour long intervals. This process will make logging short duration tasks simpler. In UH, the proposed log sheet uses a matrix system with a time interval on one axis of the matrix and a list of tasks on the other axis. The nurse would check the appropriate box for the time and task. This log sheet would save time and mental stress for the RRT nurses and would reduce time needed for administrative assistants to convert the time logs to electronic form. Overall, both improved log sheets likely would accurately capture individual tasks done by each RRT nurse, not just the category of work being done.

Page | 1

Introduction The Department of Nursing at the University of Michigan Hospital wanted to evaluate the Rapid Response Team (RRT) nurses’ workflow in both University Hospital (UH) and C.S. Mott Children’s Hospital (Mott). The RRT nurses in UH currently log their daily activities by hand during their shifts. These logs suggest that during most shifts nurses spend just over half of their time performing duties not affiliated with the RRT. The Nurse Operations Manager indicated the logs may not accurately capture the nurses’ workflow. Therefore, the Nurse Operations Manager wanted to more accurately understand how the nurses are working and know the overall effectiveness of the RRT. The Industrial and Operations Engineering (IOE) 481 team (project team) observed the nurses during their shifts in both the Pediatric Intensive Care Unit (PICU) and Surgical Intensive Care Unit (SICU) to analyze their workflow and develop recommendations to allow the nurses’ efforts to be best utilized. This final report presents the findings of the nurses’ workflow from September 8 through December 11, 2008.

Goals and Objectives The primary goal of the project was to measure and analyze the workload of the RRT nurses. In addition, the project team’s objectives included:

- Determining staffing requirements based on an analysis of how nurses utilize their time - Reformatting nurses’ current log sheets to easily and accurately record nurses’ time usage - Evaluating the effectiveness of RRT in UH and Mott

o Determining if implementing the RRT has reduced respiratory and cardiac arrests (i.e. dispatch codes)

o Analyze possible tasks for nurses to complete during unused on-call time

Background RRT originated at the University of South Wales’ Liverpool Hospital in Sydney, Australia in February 1990. The University of Michigan Health System first implemented the RRT in UH in November of 2005 in units 6B and 6C. By July 24, 2007, the RRT covered all inpatient areas in both UH and Mott. Currently, the hospital administration has allocated 5.08 Full Time Equivalent (FTE) units for the UH RRT and 2.5 FTEs for Mott RRT outside the general nursing budget. RRT is a preventative measure that responds to calls regarding patients exhibiting preliminary symptoms of cardiac or respiratory arrest. Ideally, this team will take preventative actions as soon as the symptoms start occurring. RRT responds to issues such as “acute changes in patients’ clinical status such as low blood pressure, difficulty breathing or altered mental status.”1

1 UMHHC Rapid Response Team (RRT) Implementation Plan at http://www.med.umich.edu/i/safety/Patient/rapidresponse.htm

Any clinical staff can call the RRT by contacting paging services. The team consists of an Intensive

Page | 2

Care Unit (ICU) nurse, a respiratory therapist (RT) and a physician. In Mott, the PICU Fellow and Hospitalist respond to every RRT call at the onset. In UH, the registered nurse (RN) and respiratory therapist (RT) respond, briefly evaluate the patient, and either collaborate with the primary medical service or activate the RRT physician (either the Surgery Critical Care Fellow or a Hospitalist). The patient’s primary physician is notified when an RRT call is initiated; however, the physician is not required to be present during the call. Every member of the RRT has backup personnel in case of a concurrent call. For example, the Charge Nurse responds for the corresponding ICU nurse if the ICU nurse is attending to another call. Based on the information provided from the Nurse Operations Manager, the RRT response can last between 1 and 870 minutes. UH averages 3.9 calls per day, which average 61 minutes per call. Mott averages 0.32 calls per day, which average 58 minutes per call. When nurses are not responding to a call, they perform the following activities:

- Educating: reminding other personnel of RRT availability and usage, teaching patient care techniques (i.e. IVs, reading patient vital signs, computer training)

- Rounding: walking the halls and checking in on patients and staff - Follow Up: following up on patients who in the past 24 hours have had an RRT call or

have been transferred from an ICU - Other: assisting in the SICU/ PICU, reporting, providing institutional support, following

up on previous arrest calls The UH RRT nurses record their daily activities on standardized logs (see Appendix A). The Nurse Operations Manager would prefer these to be filled out throughout the day after each activity. However, it is unclear if this practice is being followed. With these logs, the Nurse Operations Manager charted and analyzed the nurse activity to see how they utilized their day.

Project Plan The project team examined the effectiveness of time and workload of the RRTs in UH and Mott. The primary people involved in the project were the Nurse Operations Manager, Senior Management Engineer of the Program and Operations Analysis Department, SICU nurses, RRT members, PICU nurses, Director of Finance and Assistant to the Chief of Nursing from Nursing Administration, and the National Registry of Cardio-Pulmonary Resuscitation (NRCPR) Database Coordinator.

Key Issues The following are the key issues that were driving the need for the project:

- RRT workload is perceived to be imbalanced - Amount of on-call time not spent responding to RRT calls leads to inefficient use of

nurses’ time - Uncertainty of proper FTE allocation

Page | 3

Project Scope The project included evaluating the current state of the RRT nurses’ workload in UH and Mott. For UH, the project mainly focused on the time RRT nurses spent in the SICU when not responding to a call; for Mott, the project mainly focused on the time RRT nurses spent in the PICU when not responding to a call. The project also examined the nurses’ time logging process and considered possible revisions to the log sheets. The project team analyzed the logs to identify where nursing workload might be improved (i.e. reducing personal/non-value added time) and determined if the current FTE budgets are appropriate. With the collected information and noted observations, an assessment of the number of cardiac and respiratory arrests determined if the implementation of the RRT has been effective. The project scope did not include analyzing the RRTs’ actual response processes. It also did not include evaluating the RRTs’ performance or implementing the RRT in other areas of the hospital for neither present nor future use. Finally, it did not include evaluating the interactions of RRT personnel.

Expected Impact and Outcomes Based on data collection and analysis, areas of improvement in workload were identified for the RRT. These areas included the following:

- Identifying where reallocation of over- or underutilized FTEs of the RRT can occur - Redistributing RRT nursing workload to maximize the value of RRTs’ daily contribution - Reformatting the current time log or developing a new time log document for greater

accountability of the RRTs’ workday - Determining findings on overall effectiveness of cardiac and respiratory arrest reduction

Data Collection As shown below, all aspects of the project were completed as of December 11, 2008. The project team collected 41 hours of data in UH and 40 hours in Mott. This section details the data collection methods used during the project.

Receipt of Existing Data The Nurse Operations Manager provided existing RRT nurse time log data – between April 21 and June 1, 2008 – from UH, and the Clinical Nurse Manager (PICU) provided 16 months of existing RRT nurse time log data – beginning in July 2007 – from Mott. Additionally, the Nurse Operations Manager provided historical information regarding the RRT. The literature included previous analysis of nurse time log data from UH as well as records and

Page | 4

statistics on the frequency and duration of all previous RRT calls. The number of arrests after the implementation of RRT was also included in this data.

Interviews On October 14, 2008, the project team met with the Director of Finance and the Assistant to the Chief of Nursing to discuss budgeting and any concerns that could arise with the project.

On October 6, 2008, the PICU Nurse Manager and PICU Clinical Nurse Specialist were interviewed to familiarize the project team with the Mott RRT processes and determine expected impacts and goals for the project.

On September 30, 2008, the project team met with the SICU Nurse Manager, as well as the SICU Clinical Nurse Supervisor, in order to gain background information including previous history of the RRT program and expected impacts and goals for the project. The project team also met with the NRCPR Database Coordinator, who also is a SICU staff nurse, on October 1, 2008 to discuss various methodologies for data collection as well as metrics to determine RRT effectiveness.

Time Studies The project team observed the workload of RRT nurses in approximately 4 hour increments of time. The observed data included all activities performed by the RRT nurses while being observed during a segment of their shift – either between 7:00am to 6:59pm (day shift) or 7:00pm to 6:59am (night shift). This information was used to refine the workflow sheets (see Appendix B and C).

Since the RRT program varies between Mott and UH, data was collected in groups of two, meaning that two project team members collected data in Mott while the other two project team members collected data in UH. A total of 81 hours were collected between both hospitals – 41 hours collected in UH and 40 hours collected in Mott. The project team followed 8 different nurses in both Mott and UH. All project team members used the data collection sheet in Appendix D to log observational data (see Appendix D). All observations were performed between 7:00am and 11:59pm. The table below displays the total minutes spent in Mott during a specified period of time (see Table 1) and the respective percentages towards total time collected.

Page | 5

Table 1: Distribution of Time Spent Collecting Data in Mott

Time Interval 7am to 12:59pm 1pm to 6:59pm 7pm to 11:59pm

Total Minutes Spent (m) 1,008 722 674

Total Time Percentage (%) 42 30 28 This table shows 72% of data was collected during the day shift and 28% during the night shift. The table below displays the total minutes spent in UH during a specified period of time (see Table 2) and the respective percentages towards total time collected. Table 2: Distribution of Time Spent Collecting Data in UH

This table shows 90% of data was collected during the day shift and 10% during the night shift.

Findings Listed below are the findings from the interviews, historical data, and times studies. Each category is broken into Mott and UH findings; furthermore, the Findings from Interviews section contains Nursing Administration findings.

Findings from Interviews Below are the findings from the aforementioned interviews.

Nursing Administration During these discussions, the project team found that both the Director of Finance and the Assistant to the Chief of Nursing were concerned about how to evaluate the effectiveness of the RRT and were interested in learning in greater detail how the Mott RRT program functions. The quantitative breakdown of Mott RRT nursing workload was not communicated to Nursing Administration, even though this data was readily available.

Mott Personnel The Clinical Nurse Specialist and Nurse Manager reported that the PICU RRT nurses currently log their daily activities on sheets using a matrix of time slots and categories (see Appendix B

Time Interval 7am to 12:59pm 1pm to 6:59pm 7pm to 11:59pm

Total Minutes Spent (m) 1708 488 244

Total Time Percentage (%) 70 20 10

Page | 6

and C). The nurses check a box to indicate the time and activity done. The PICU also has a slightly different definition and protocol for what encompasses an RRT call. In the PICU, a physician accompanies a nurse and RT on all calls and then determines which of the members need to remain on the call. During rounding, the RRT nurse asks other nurses if they have any concerns about their patients and, if so, the RRT nurses assist with care similar to a call. This additional support is not reflected in the logs as an RRT call. Moreover, management reported that the Mott RRT program is funded with 2.5 FTEs paid by Central Staffing and 2.58 FTEs paid by the PICU.

UH Personnel The Nurse Manager and Clinical Nurse Supervisor provided background information about the UH RRT to familiarize the project team with its details. The SICU Nurse Manager and Clinical Nurse Supervisor reported that UH receives approximately 30 to 35 RRT calls per week. However, management believes RRT can, at times, be staffed inappropriately. Currently, Central Staffing funds 5.08 FTEs for the UH RRT. The NRCPR coordinator discussed the need for additional data collection hours for accurate data, as well as what information to capture during time studies including how to avoid the Hawthorne effect. The Hawthorne effect occurs when the presence of an observer during an activity can lead a worker to respond or act differently than he/she normally would. The NRCPR coordinator expressed that the time of day or day of the week should not matter in collecting data as no difference in the workload was evident. Findings from Historical Data The information provided by the Nurse Operations Manager reported that Mott averages 0.32 calls per day that last on average 58 minutes, and UH averages 3.9 calls per day that last on average 61 minutes. The information also contained graphs with RRT call rates and dispatch code rates for both Mott and UH. The Mott data can be seen below in Figure 1.

Page | 7

Figure 1: Number of RRT Calls and Dispatch Codes per 1000 Discharges in Mott

The figure above shows no significant change in dispatch codes even after RRT implementation. Below, the UH data can be seen in Figure 2. Figure 2: Number of RRT calls and Dispatch Codes per 1000 discharges in UH

The figure above shows no significant change in dispatch codes even after RRT implementation. According to the historical RRT data in UH, during the time period of April 21 to June 1, 2008, there were 12 simultaneous calls that accumulated a time of 340 minutes and twice there were 3 simultaneous calls that accumulated a time of 7 minutes.

Page | 8

Findings from Time Studies Time studies were done in both hospitals with the findings listed below. Each hour value shown on the figures represents the amount of time spent on a given task in a 24-hour work day. Each percentage value shown on the figures represents the percentage of time spent on a given task, based on the respective graph. Mott Time Studies The observed time log data was grouped into three main categories: RRT core, PICU support, and Miscellaneous. The figure below depicts the amount of time spent by the RRT nurses performing duties in each of the given categories (see Figure 3). Figure 3: Time Breakdown of the Major Activities in Mott for Historical and Observational Data

This figure shows some dramatic differences between the historical and observed data in the PICU support and Miscellaneous categories. This fact will be discussed in detail in the Mott conclusions section (see Mott Conclusions). Breaking down the RRT core category shows 5 activities performed by the nurses. These activities are shown in Figure 4, which are broken down by time spent performing these tasks (see Figure 4).

RRT core6.84 hr

28%

PICU support16.70 hr

70%

0.45 hr2%

Historical Data

RRT core

4.51 hr19%

PICU support11.81 hr

49%

7.68 hr32%

Observational DataRRT log 07/01/08-10/31/08

40 hrs of observation between 7am-11pm from 10/13/08-11/18/08

Miscellaneous

Miscellaneous

Page | 9

Figure 4: Time Breakdown of RRT Core Category in Mott

These tasks are considered RRT core work. As shown in the above figure, the activity most often performed is Rounding/Follow Up. Although the nurses are not required to round in Mott, some nurses talk to the Charge Nurses on the floors during follow up, especially if they were unable to talk to the charge nurse at Bed Meeting. The definition of a Nurse Consultation is a RRT nurse visit to the floors to assist with a patient although a RRT call was not initiated. Many times a floor nurse will not see the need for a full call but would like assistance regarding a difficult situation. It should be noted that there were no observed RRT calls. The following figure shows the time breakdown of PICU support (see Figure 5).

Report0.93 hr

21%

Bed Mtg0.70 hr

15%

Education0.68 hr

15%

Rounding/ Follow Up

1.81 hr40%

Nurse Consultation0.40 hr

9%

40 hrs of observation between 7am-11pm from 10/13/08-11/18/08

Page | 10

Figure 5: Time Breakdown of PICU Support in Mott

The largest portion of time spent in PICU support is Other PICU Patient Care. This category was developed because of the large number of tasks completed by the nurses when assisting in the PICU. However, common tasks of covering for other nurses and assisting with admissions and transfers on the unit account for large portions of the nurses’ PICU support.

Further breaking down the Other PICU Patient Care category from Figure 5 is seen in the next figure (see Figure 6).

IV0.36 hr

4% Admit/ Transfer On Unit

1.56 hr15%

Other PICU Patient Care

7.23 hr70%

Cover for Bedside RN

1.14 hr11%

40 hrs of observation between 7am-11pm from 10/13/08-11/18/08

Page | 11

Figure 6: Time Breakdown of PICU Support – Other PICU Patient Care in Mott

As we can see from the above figure, RRT nurses complete a wide variety of tasks related to patient care in the PICU. Unclassified Bedside Assistance consisted of tasks performed by nurses assisting with bedside care that could not be easily distinguished or readily defined by a specific category. The Miscellaneous category is broken down into specific activities in the following figure (see Figure 7).

Draw Blood/Deal With Blood Sample

0.46 hr6%

Assist With Drips/Meds

0.59 hr8%

Assist With Suction0.21 hr

3%

Unclassified Bedside Assistance

1.52 hr 21%

Bed/Diaper Change0.51 hr

7%Running Errands

On Unit0.68 hr

10%

ECMO Assistance0.10 hr

1%

Temporary Patient Assignment

0.44 hr6%

CT Scan Prep/Assistance

0.61 hr8%

Monitor/Cart Checks0.55 hr

8%

CRRT Initiation Work

1.56 hr22%

40 hrs of observation between 7am-11pm from 10/13/08-11/18/08

Page | 12

Figure 7: Time Breakdown of Miscellaneous Activities in Mott

Personal/Non-Value Added Activities accounted for over 5.5 hours of nurses’ time – the largest portion of their Miscellaneous activities. During the time studies, the project team noted that PICU staffs the unit knowing that the RRT nurse will be contributing roughly 50% of their time to the unit. To do this, the PICU has assigned daily tasks to the RRT nurse such as checking crash carts, transport monitors, and gloucometers. Also, patient assignments are made with knowledge that the RRT nurse will be on the unit to provide assistance. UH Time Studies Similar to the Mott figures, the observed time log data was grouped into three main categories: RRT core, PICU support, and Miscellaneous. The figure below depicts the amount of time spent by the RRT nurses performing duties in each of the given categories (see Figure 8).

Project Work1.54 hr

20%

Lunch/ Dinner0.51 hr

7%

Personal/Non-Value Added

Activities5.63 hr

73%

40 hrs of observation between 7am-11pm from 10/13/08-11/18/08

Page | 13

Figure 8: Time Breakdown of Major Activities in UH for Historical and Observational Data

The largest discrepencies between historical and observed data appeared in the Miscellaneous and SICU support categories. This discrepancy is discussed in detail in the UH conclusions section (see UH Conclusions). Breaking down the RRT core category shows 7 activities performed by the nurses. These categories are shown in the figure below (see Figure 9). Figure 9: Time Breakdown of RRT Core Category in UH

Most of the RRT core time is spent responding to RRT calls or performing Rounding/Follow up.

RRT core

13.39 hr

56%

SICU support8.74 hr

36%

1.87 hr 8%

Historical Data

RRT core11.61 hr

48%

SICU support3.73 hr

16%

8.67 hr36%

Observational Data

Report0.98 hr

9% Bed Mtg1.12 hr

10%

Education0.66 hr

6%

Rounding / Follow up

4.56 hr40%

Nurse Consultation*

0.29 hr2%

RRT Call 3.18 hr

28%

Admit/Transfer After Call0.61 hr

5%

40 hrs of observation between 7am-11pm from 10/13/08-11/18/08

RRT log 04/21/08-06/01/08

Miscellaneous Miscellaneous

40 hrs of observation between 7am-11pm from 10/13/08-11/18/08

Page | 14

The following figure represents the breakdown of time an RRT nurse spends performing SICU support activities (see Figure 10). Figure 10: Time Breakdown of SICU Support Category in UH

The majority of the SICU support is performing Other SICU Patient Care. Bathing/changing was an observed activity not noted in Mott observations. The figure below shows the breakdown of Miscellaneous activities (see Figure 11).

IV 0.51 hr

13%

Bathing/changing0.89 hr

22%

Admit/ Transfer On Unit

0.67 hr16%

Other SICU Patient Care

1.60 hr39%

Cover for Bedside RN0.39 hr

10%

40 hrs of observation between 7am-11pm from 10/13/08-11/18/08

Page | 15

Figure 11: Time Breakdown of Miscellaneous Activities in UH

As shown in the figure above, the majority of the Miscellaneous activities was spent performing Personal/Non-Value Added Activities. The project team noted that the SICU does not staff accounting for the RRT nurse being on the unit for any portion of time to assist. Because SICU does not staff with the RRT nurse in consideration and does not require RRT to perform specific tasks on the unit, most of the Personal/Non-Value Added Activities time is spent searching for work in the SICU.

Conclusions The historical and observed data gave a representation of both the UH and Mott RRT. Even though the RRT offers the same services to their respective hospital, UH and Mott RRTs differ in the way they operate. The project team evaluated and identified the most efficient aspects of each team as well as areas for improvement. Mott Conclusions After reviewing the observed data, the project team compared the results to the historical data – from July 1 through October 31, 2008 – provided by the PICU Nurse Manager. This amount of data provided a significantly large sample size with which to compare the observed data, and the categories of nurses’ activities were consistent across the entire sample. In comparing the observed data to the historical data in the overall category breakdown (see Figure 3), a discrepancy of 2.33 hours per 24 hour day in RRT core work was prevalent. This can

Project work0.21 hr

2% Lunch / Dinner1.00 hr

12%

Personal/Non-Value Added

Activities6.18 hr

73%

Repacking RRT bags0.64 hr

7%

Meetings in SICU0.49 hr

6%

40 hrs of observation between 7am-11pm from 10/13/08-11/18/08

Page | 16

be partially attributed to the lack of RRT calls observed by the project team. Using average call rates over the 4 months of historical data, the project team expected to see 0.83 calls during the 40 hours of data collection. However, no calls occurred during data collection, so this caused an expectation to see 0.48 hours per 24 hour day less RRT core time than the historical data. Even accounting for this issue in the data, the project team still observed 1.85 less hours per 24 hour day of RRT core work than would be expected. A 1.85 hour difference between historical RRT core work and observed RRT core work is not an overly drastic difference between the two data sets. Because of the sample size of observed data, much of the difference could have been observing less busy days that would have otherwise been accounted for in the historical data. This fact led the project team to conclude that there is not a significant difference between the RRT Core historical data and observed data. When examining the PICU support and Miscellaneous categories (see Figure 3), the project team first noticed a discrepancy of 4.89 hours and 7.23 hours per 24 hour day between the historical and observed data. However, after examining the change in expected RRT core work, the project team had to calculate new expected values for PICU support and Miscellaneous categories to compare to the observed data. By keeping the ratio of non-RRT core time the same as historical data, the expected values for PICU support and Miscellaneous categories became 17.15 hours and 0.49 hours per 24-hour day, respectively. However, during data collection it was noticed that nurses were logging their Personal/Non-Value Added Activities time as PICU support because there was no place to log Personal/Non-Value Added Activities time. To account for this inaccuracy in the logging process, the project team assumed that the historical data actually contained the same amount of Personal/Non-Value Added Activities time as the observed data. This time was then reclassified as Miscellaneous time in the historical data and the correct expected values for PICU support and Miscellaneous activities were recalculated to be 11.52 hours and 6.12 hours per 24-hour day. Comparing the observed values for PICU support and Miscellaneous activities, the discrepancies were 0.29 hours and 1.52 hours per 24-hour day, respectively. By examining the discrepancies between historical data and observed data for RRT core, PICU support, and Miscellaneous activities, the team concluded that the historical logs are accurate representations of the amount of work being done in each of the three main categories with the exception of the Personal/Non-Value Added Activities time logging process. After reviewing the in-depth expansions of the main three categories (see Figures 4 through 7), the project team observed a large variation of activities based on the nurse being observed and the time of day. The nurses communicated that particular jobs done in PICU support and in Miscellaneous activities were decided by the nurse. In the PICU, the RRT nurse does have some assigned duties during the shift that must be completed, but the majority of support work is found by the nurse looking for work that needs to be done at that time. Because of the nature of PICU work, numerous activities arise throughout the day, and the needs of the unit can change instantly. This uncertainty makes it difficult to draw strong conclusions as to exact amounts of time nurses spend on particular PICU support or Miscellaneous activities. Once the project team amassed all time study data, it examined the budget of the program and compared it to the observed work being done. Below is a table summarizing the budget and the

Page | 17

amount of work being done in terms of FTEs (see Table 3). The “Observed Usage of FTE” column is derived from the percentage of time done for an activity and taking the same percentage of the overall FTE budget. Table 3: Comparison of Funding and FTE Work Usage in Mott

Funding Source Central Staffing (RRT) PICU Miscellaneous Total

Current Funding (FTE) 2.50 2.58 0.00 5.08

Observed Usage (FTE) 0.97 2.49 1.62 5.08 From this table, the project team noticed the large difference between the funding paid by Central Staffing and the amount of work being done on Central Staffing jobs. Currently, all of these jobs are RRT core jobs. The project team concluded the difference needs to be minimized to eliminate wasted funding by either lowering the funding provided or finding alternative jobs that would serve Central Staffing needs. When comparing the funding paid by PICU and the work it receives in return, the number is very close, indicating PICU is paying an appropriate share of the funding. To become more efficient, Miscellaneous needs to have a minimal amount of FTE usage since it is in no way funded. All Mott RRT nurses consulted about the log sheet used currently expressed satisfaction with the matrix design and ease of use. The matrix time sheet made entering logs into electronic form very clear with specified amounts of time for specific tasks. However, a slight problem arose when a nurse performed a task for less than an hour. Since the log sheets use hour long intervals, the nurse would have to check two boxes on the same row. This practice was observed to be common when completely the log sheet. However, this practice was not required and sometimes certain activities were logged improperly by either overestimating or underestimating the length of task. The project team determined a shorter time interval may help increase the accuracy of the logs by giving the nurses a more standard way to log activities shorter than one hour. While some other hospitals report significant decreases of dispatch code rates after implementing RRTs, upon analysis of the historical data regarding RRT call rates and dispatch code rates in UH and Mott, the project team was unable to detect a numerical effect on dispatch code rates by implementing RRT in UH and Mott. However, the Nurse Operations Manager as well as the Assistant to the Director of Nursing reported strong findings through soft metrics and surveys that the RRT team improves the level of care provided to patients. An example of improved care appears through other nurses feeling more confident treating their own patients, knowing they have help if the patient’s situation deteriorates. These metrics indicate that there is a utility provided by the RRT, but, currently, this is not being captured in the dispatch code metric. UH Conclusions After reviewing the observed data, the project team compared the results to the historical data – from April 21 through June 1, 2008 – provided by the Nurse Operations Manager. This amount of data was chosen because it provided a significantly large sample size with which to compare the observed data, and the data was readily available.

Page | 18

The project team first examined the discrepancy between the historical and observed RRT core data (see Figure 8). At first glance, it appeared that the discrepancy was simply 1.78 hours per 24 hour day. However, using historical average RRT call rates, the project team expected to observe 5.5 RRT calls during the observed data time period. The observed data only showed 3 RRT calls during this time, so it would be expected for there to be less observed RRT core work. This lack of calls translated into a decreased expected RRT core work time of 1.53 hours per 24 hour day from the historical data. After accounting for the lack of calls, the expected RRT core work became 11.86 hours per 24 hour day, meaning the discrepancy in the RRT core category between the expected data and observed data became just 0.25 hours per 24 hour day. The project team first noticed a discrepancy of 5.01 hours and 6.8 hours per 24 hour day between the SICU support and Miscellaneous categories (see Figure 8). However, after examining the change in expected RRT core work, the project team had to calculate new expected values for SICU support and Miscellaneous categories for the observed data. By keeping the ratio of non-RRT core time the same as historical data, the expected values for SICU support and Miscellaneous categories became 9.93 hours and 2.21 hours per 24 hour day respectively. However, the team noticed during data collection that there was no place to log Personal/Non-Value Added Activities time, so nurses logged this time as SICU support. To account for this inaccurate form of logging, the project team assumed the same amount of Personal/Non-Value Added Activities time in the historical data as was present in the observed data and then reclassified the Personal/Non-Value Added Activities time as Miscellaneous activity in the historical data. The project team found 6.18 hours per 24 hour day of the observed Miscellaneous time to be Personal/Non-Value Added Activities time. The expected values for SICU support and Miscellaneous categories were then recomputed and found to be 3.75 hours and 8.39 hours per 24 hour day respectively. When these expected values were compared to the observed data, the discrepancy between SICU support and Miscellaneous activities became 0.02 hours and 0.28 hours per 24 hour day respectively, much lower than the initially noticed values. Finding the differences between expected and observed data in RRT core, SICU support, and Miscellaneous all to be less than 0.3 hours per 24 hour day, the project team concluded that the historical data is an accurate representation of the nurses’ current workload with the exception of the Personal/Non-Value Added Activities logging practice. After examining the broad category comparisons between historical and observed data, the project team analyzed the in-depth expansions of the main three categories (see Figures 9 through 11). After performing this analysis, no strong conclusions could be drawn about the specific amounts of time nurses spent on tasks within each category. The project team observed a high variation of tasks depending on the nurse and time of day. Since there are no assigned tasks during non-RRT call time, nurses differed as to what to do during these periods. Some nurses spent more time trying to help the patients in the unit while others waited for other staff to ask for help. Moreover, rounding differed from nurse to nurse in regard to length; some were more detailed than others in finding out the status of patients on the floor. Because of these numerous factors, no concrete conclusions could be drawn about specifics within categories.

Page | 19

Once the project team amassed all time study data, it examined the budget of the program and compared it to the observed work being done. Below is a table summarizing the budget and the amount of work being done in terms of FTEs (see Table 4). The “Observed Usage of FTE” column is derived from the percentage of time done for an activity and taking the same percentage of the overall FTE budget. Table 4: Comparison of Funding and FTE Work Usage in UH

Funding Source Central Staffing (RRT) SICU Miscellaneous Total

Current Funding (FTE) 5.08 0.00 0.00 5.08

Observed Usage (FTE) 2.44 0.81 1.83 5.08 From this table the project team noticed a large difference between the funding paid by Central Staffing and the amount of work being done on Central Staffing jobs. Currently, all of these jobs are RRT core jobs. The project team concluded the difference needs to be minimized to eliminate wasted funding by either lowering the funding provided or finding alternative jobs that would serve Central Staffing needs. Also, because SICU is receiving approximately 0.8 FTE of work, management should investigate possible funding coming from the SICU to pay for this work. To become more efficient, Miscellaneous needs to have a minimal amount of FTE usage since it is in no way funded. Due to its limited detail, the previous log sheets did not offer enough specific data to draw comparisons from historical data. The figure below illustrates the limited ability of the current log sheet to capture specific tasks done within a category (see Figure 12). Figure 12: Historical RRT Core - Category Breakdown

Report1.5011%

Rounding / Follow up

6.7250%

RRT Call 5.1739%

40 hrs of observation between 7am-11pm from 10/13/08-11/18/08

Page | 20

This figure only displays time data about three activities within RRT core work. Comparing this figure to the observed data for the RRT core breakdown (see Figure 9), the historical data cannot capture categories such as Bed Meeting, Education, Nurse Consultation, and Admit/Transfer After Call. The limits of this log sheet do not allow management to get a specific look into the tasks RRT nurses are performing. From this information, the project team concluded UH should collect data with more detailed categories to standardize more specific breakdowns of tasks and more effectively capture the time each individual tasks requires. During data collection, the project team noticed that the current log sheet used to write RRT tasks (see Appendix A) uses general categories, and the RRT nurse is required to write in the type of activity and show how long they spent doing a particular activity. The sheet is not user-friendly as nurses have to manually write all the information and times. It is an open ended sheet that leads to a lack of standardized logging. Finally, the current log sheet makes it difficult for management to input the data into an electronic database because the categories are insufficient to truly capture the nursing workload. This shortcoming forces nurses to create categories or log excessive “other” time, which leads to open interpretation of the logs. Because of these facts, the project team concluded that an easier to use, more standardized log sheet would save RRT nurses and administrative assistants time and effort in completing and interpreting the log sheets. Similar to the observed data in Mott, the project team was unable to determine a numerical effect on dispatch code rates in UH after the implementation of RRT (see Mott Conclusions).

Recommendations The following recommendations were derived after analyzing the collected data and discussions with the client. Mott Recommendations After reviewing the discrepancies between the amounts of funding provided to the RRT by the PICU and Central Staffing, the project team is recommending maintaining the current number of FTEs the PICU pays for the RRT. Since the amount of work the PICU receives closely aligns with the funding it provides, no change is necessary at this time. To address the more than 1.5 FTE discrepancy between Central Staffing funding and work received, there are two options to investigate. The first would be to reduce funding provided by Central Staffing. The project team does not recommend this option. Because of the on-call nature of the RRT role, management must allow for a portion of time that is not necessarily direct RRT core work to account for variability in the number of calls. A representative analogy for this situation is a fire station. The firemen must always be on-call so they can respond to a fire at any time for any duration of time, since it is impossible to predict when and how long a fire will occur. In the same manner, nurses must be available during the day to respond to a call at any time for any duration of time. Each day will be different, and the nursing workload cannot be designed without a buffer of downtime or else the nurse will not be able to respond during high volume days.

Page | 21

The second option is to maintain the current Central Staffing funding and find project work that benefits the entire hospital. This work would not have to be done at a certain time; therefore the nurse could drop the work in the event of a call and restart the work at the conclusion of the call. Examples of project work would be the Committee on Pain and Sedation and Family Centered Care projects. This work benefits the entire hospital, would increase the FTEs used for Central Staffing, and would maintain the functionality of the RRT nurse. Other options of using bedside nurses or Charge Nurses as RRT have been investigated; but since the patients cannot be left at the bedside, these options have not been effective models of RRT. Using a portion of time to assist on the unit allows the RRT nurse to perform unit tasks that can be dropped if necessary, but a patient assignment does not allow the same flexibility. The challenge of giving RRT nurses project work is the large number of RRT nurses in rotation. Mott currently uses 40 nurses in the RRT rotation and a nurse may not rotate into the role for a month. The hospital does not have enough projects going on simultaneously to give 40 nurses jobs on projects, and even if there were a large number of projects, only using one shift per month to work on a project would not contribute much. To alleviate this problem, the rotation could be reduced, but enough nurses must stay on rotation so the nurses do not lose their PICU skills. Although the large rotation poses possible problems, the project team recommends management further investigate giving project work to nurses to fill the RRT nurses’ on-call time. Although the project team concluded that the log sheet was an accurate representation of the nurses’ activities for the RRT Core, PICU Support, and Miscellaneous activities, to further improve the sheet, when recording information about specific activities, the project team recommends investigating breaking the time intervals down from one hour to 30 minutes. The project team noticed that many of the activities take less than an hour and nurses must check multiple boxes for a one hour period. Converting to 30 minute intervals would help the nurses effectively capture their workload (see Appendix E and F). UH Recommendations UH is fully funded by Central Staffing; therefore, the expectations for the workload distributions differ from Mott. In recommending possible areas to improve the workload of UH RRT nurses, the project team suggests UH further investigate using Mott’s model in UH. The RRT nurses in UH have a higher volume of calls, so UH RRT cannot be budgeted with 50% funding from a single unit; however, the SICU can fund the amount of time that the nurse currently spends providing support. This model will help to efficiently use the extra RRT nurse that is available. A potential challenge is deciding the amount of buffer time needed to account for variability. Because of the high volume of UH calls, it is conceivable that on days with a greater than average number of RRT calls, the RRT nurse could spend the majority of time on calls and other core RRT work. If the likelihood of this scenario is deemed too high to effectively implement, savings can be found through alternatives. An alternate course of action would be assigning hospital project work to the RRT nurse, similar to the option discussed in the Mott Recommendations section (see Mott Recommendations). With project work such as the Family Centered Care project, RRT nurses could work during

Page | 22

non-RRT core time and not have to worry about leaving a patient in need of care. A potential challenge would be the changing designation of the RRT nurse. UH uses 35 RRT nurses in the rotation, so there would not be enough projects for every nurse, and assigning too many nurses to a project would lead to inefficiencies. This alternative would work best if RRT could match an appropriate number of nurses to the average number of projects the hospital usually undertakes at a given time. After reviewing the feasibility of the two options and the success of the Mott model, the project team recommends to examine the Mott model and then examine how project work could be integrated to maximize nurses’ utility. Based on the conclusions about the current log sheet, the project team recommends implementing a matrix type log sheet similar to the style used in Mott. However, in developing the UH sheet, the categories on the log sheet must be customized to the work being done most frequently in UH. The project team revised the current time log sheets which can be found in Appendices G and H (see Appendix G and H). The revised log sheets contain the appropriate categories that accurately reflect daily RRT nurse tasks and are formatted to be user friendly, efficient, and accurate. The logging process would take less time, because it would require the nurse to check the category that he/she completed. The revised log sheet is broken down into time intervals of 30 minutes, which would require nurses to be specific about their time allocation. Additionally, more categories are present in the project team’s log sheet in order to give management a better understanding of the RRT nurses’ work allocation.

Acknowledgements The team metis meeting weekly or bi-weekly with the client and the project coordinator, both of whom discussed advise the current status and direction of the project. In addition tThe client helped coordinate meetings with required staff and provided previous log data. The following people are participating in this project: Jason Maynard, Nurse Operation Manager (RN), Client Sam Clark, Senior Management Engineer (POA), Project Coordinator MaryAnn Bettis, Nurse Manager, Surgical ICU and Adult RRT Sharon Dickinson, Clinical Nurse Specialist, Surgical ICU and Adult RRT Daniel Lagrou, SICU Clinical Nurse Supervisor Julie Juno, Nurse Manager, Pediatric ICU and Pediatric RRT Annette Scott, Clinical Nurse Specialist, Pediatric ICU and Pediatric RRT Kathleen Moore, Nursing Administration, Director of Finance Barb Wetula, Nursing Administration, Assistant to the Chief of Nursing

Page | 23

Ernie Saxton, Staff Nurse, Surgical ICU and NRCPR Database Coordinator, Office of Clinical Affairs

Page | A

Appendix A: Current UH RRT Time Log Examples

Page | B

Appendix B: PICU 7:00am to 7:00pm Log Sheet

Page | C

Appendix C: PICU 7:00pm to 7:00am Log Sheet

Page | D

Appendix D: Team Data Collection Sheet date:

TIME Report Bed Mtg RRT Call -

Acute care ICU Unit

patient care

ICU Unit admin work

ICU Unit project work

Rounding / Follow

up

Lunch / Dinner Tasks

CRRT Initiation

work

Admit / Transfer Other

FROM UNTIL

Other common activities:

Page | E

Appendix E: Modified Mott RRT AM Time Log

Page | F

Appendix F: Modified Mott RRT PM Time Log

Page | G

Appendix G: New UH RRT AM Time Log

Page | H

Appendix H: New UH RRT PM Time Log