Is three greater than two?

Introduction: The previously established pediatric inpatient wards team structure consisted of two teams, each made up of a senior resident, junior resident and two intern residents. With increasing patient volumes and complexity, the workload for each team member became burdensome, resulting in a suboptimal educational experience, high cognitive load, lack of consistent patient-centered care, delayed discharges, stressful team dynamics and provider fatigue and burnout. Data is limited on the optimal resident-to-patient ratio to maximize education and optimize cognitive load, however there are studies that tie excessive work-load and high fatigue to resident burnout.^1,2 Our aim was to adjust the team structure by creating three teams to more evenly distribute the patient load, thereby, optimizing the resident educational experience, improving team morale, and advancing patient care as measured by qualitative assessment of residents’ experience through small focus groups.

Methods: A single site, observational time series using multiple planned interventions and Plan-Do-Study-Act (PDSA) cycles to rapidly implement changes to the structure of the ward’s teams was used to achieve the stated aims. Two PDSA cycles were observed to evaluate the data and adjust the structure accordingly. The intervention was studied using both quantitative data and qualitative data. The quantitative data included monitoring patient volume and division amongst the three teams and utilizing a run chart to determine shifts or trends in median patient team census. Qualitative data elicited by the chief residents every other week at the conclusion of a particular educational section and the feedback was evaluated to assess for emerging themes and identify additional areas for intervention.

Results: The initial intervention involved dividing the two teams into three teams, using the same number of residents but increasing the number of responding clinicians and decreasing the number of total patients per team. We saw a decrease in patient census for both the Crawford and Talbot team with median patients per team going from 15 to 11 patients and 14 to 8 patients, respectively. The new subspecialty team had a median of 10 patients. The impact of balancing measures were identified through qualitative feedback, including suboptimal support for interns early in the academic year, inefficient rounding for the subspecialty team, and lengthy sign-out processes as there continued to be only two teams on nights and weekends. A second intervention was then implemented to address the challenges surrounding sign-out and involved a different redistribution of the patients amongst the night and weekends teams, resulting in a more streamlined sign-out process.

Conclusion: While the goal of reducing the number of individuals per team was accomplished, that may not be enough to substantially reduce cognitive load, resident’s inherent sense of balance between education and service, and provider fatigue and burnout.

References

1. Harry, E., Sinsky, C., Dyrbye, L. N., Makowski, M. S., Trockel, M., Tutty, M., Carlasare, L. E., West, C. P., & Shanafelt, T. D. (2021). Physician Task Load and the Risk of Burnout Among US Physicians in a National Survey. The Joint Commission Journal on Quality and Patient Safety, 47(2), 76-85. https://doi.org/10.1016/j.jcjq.2020.09.011

2. McKinley, T. F., Boland, K. A., & Mahan, J. D. (2017). Burnout and interventions in pediatric residency: A literature review. Burnout Research, 6, 9-17. https://doi.org/10.1016/j.burn.2017.02.003