Outpatient RN Workflow Analysis Anise
1 Diaz , 1Donald
Stephanie
1 Lin ,
Dr. Safiya
1,2 Richardson
and Barbara Zucker School of Medicine at Hofstra/Northwell 2Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health
Background Registered nurses (RNs) help to standardize ambulatory care across a number of acute and chronic diseases and preventive health delivery using protocols. Unfortunately, RNs are often not empowered to use the full scope of their licenses to improve patient care. Integrated clinical prediction rules (iCPRs) are state-ofthe-art frontline decision aids that combine real-time patient history with information from the electronic health record (EHR). Empowering RNs to use iCPRs to treat acute low complexity patients, including those with sore throat and cough, may prove an effective way to decrease physician burden while maintaining similar quality and patient satisfaction to treatment from physicians. Our goal is to create and implement an RN-based iCPR tool for evaluation and treatment of patients with ARIs in primary care practices. In an effort to maximize usability of the tool, RN leadership was consulted to provide insights to the current triage workflow for consideration for tool development. This exposed a clear need for further exploration and detailing of workflow. The purpose of this study is to observe and analyze the RN workflow with particular attention to the RN triage protocol.
Results
Overall observations of the RN workflow demonstrate there are more similarities to the physician workflow than previously anticipated. RNs similarly spend their day completing many short tasks for a variety of patients. Many of these tasks did not require an RN to complete and may present an opportunity to offload some work to another team member.
Figure 1: Summary of task breakdown.
Methods Two medical students shadowed RNs at two different primary care offices in the Long Island area. Each student visited the office twice during 4 hours shifts (totaling 15.5 observed hours). The students documented each task performed including: time spent, EHR usage, physical location and brief descriptions of what was done. When appropriate details for why and how something was done was also documented. Tasks were categorized in 6 categories: clinical visit, EHR only, office administration, patient administration, phone consult, provider communication and other. Clinical time was defined to include clinical visit, phone consult and provider communication.
Additionally, RNs spend the majority of their clinical time over the phone. This is primarily for RN triage and many of the nurses find this frustrating because they often can’t directly help the patients if their symptoms don’t require an ER or urgent care visit and there aren’t open appointments in their schedule. The clinical prediction tool will empower nurses to use the full scope of their license and enable them to help low acuity patients in a more decisive and standardized fashion. Of the findings, the most unexpected is the amount of time spent on the EHR. It was hypothesized that RNs spend less time on the EHR and thus might be a good target for the iCPR tool.
Hypothesis RNs spend less time on EHR and would require more time per patient.
Conclusions
Figure 2: 34% of RN time is clinical oriented. Clinical time was defined to include clinical visit, phone consult and provider communication.
Figure 3: 82% of RN time was spent on the EMR. This includes documenting phone conversations, writing notes, checking the RN task list, etc.
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Figure 4: Further analysis of clinical time. 26% of RN clinical time was spent in person.
Although this finding is initially discouraging, the RNs reported a more positive relationship with the EHR and find it helpful for organization and prioritization of their duties. Thus, they may still be an ideal candidate for implementation of an EHR based tool.
Future Direction Future steps are to develop and implement an iCPR tool and evaluate its initial usage and effectiveness before implementing on a broader scope. One potential barrier to implementation is Covid19 where cough and sore throat are potentially high acuity symptoms and may not be appropriate for an RN to manage.