Perniciaro Jessica L, Schmidt Anita R, Pham Phung K, Liu Deborah R
Division of Emergency and Transport Medicine Children's Hospital Los Angeles Los Angeles CA.
Department of Pediatrics Keck School of Medicine University of Southern California Los Angeles CA.
AEM Educ Train. 2019 Sep 12;4(1):43-53. doi: 10.1002/aet2.10388. eCollection 2020 Jan.
Academic emergency medicine is a constant balance between efficiency and education. We developed a new model called swarming, where the bedside nurse, resident, and attending/fellow simultaneously evaluate the patient, including initial vital signs, bedside triage, focused history and physical examination, and discussion of the treatment plan, thus creating a shared mental model.
To combine perceptions from trainee physicians, supervising physicians, nurses, and families with in vivo measurements of emergency department swarms to better conceptualize the swarming model.
This mixed methods study was conducted using a convergent design. Qualitative data from focus groups with nurses, residents, and attendings/fellows were analyzed using directed content analysis. Swarming encounters were observed in real time; durations of key aspects and family satisfaction scores were analyzed using descriptive statistics. The qualitative and quantitative findings were integrated a posteriori.
From the focus group data, 54 unique codes were identified, which were grouped together into five larger themes. From 39 swarms, mean (±SD) time (minutes) spent in patient rooms: nurses = 6.8 (±3.0), residents = 10.4 (±4.1), and attendings/fellows = 9.4 (±4.3). Electronic documentation was included in 67% of swarms, and 39% included orders initiated at the bedside. Mean (±SD) family satisfaction was 4.8 (±0.7; Likert scale 1-5).
Swarming is currently implemented with significant variability but results in high provider and family satisfaction. There is also consensus among physicians that swarming improves trainee education in the emergency setting. The benefits and barriers to swarming are underscored by the unpredictable nature of the ED and the observed variability in implementation. Our findings provide a critical foundation for our efforts to refine, standardize, and appraise our swarming model.
学术性急诊医学始终在效率与教育之间寻求平衡。我们开发了一种名为“蜂群式协作”的新模式，即床边护士、住院医师以及主治医生/专科住院医生同时对患者进行评估，包括初始生命体征、床边分诊、重点病史及体格检查，以及治疗方案讨论，从而形成一种共享思维模式。
将实习医生、指导医生、护士及患者家属的看法与急诊室蜂群式协作的现场测量结果相结合，以便更好地构建蜂群式协作模式的概念。
本混合方法研究采用聚合设计。对护士、住院医师以及主治医生/专科住院医生焦点小组的定性数据采用定向内容分析法进行分析。实时观察蜂群式协作会诊情况；使用描述性统计分析关键环节的时长及患者家属满意度得分。定性和定量研究结果事后进行整合。
从焦点小组数据中识别出54个独特编码，这些编码被归纳为5个更大的主题。在39次蜂群式协作会诊中，在病房花费的平均（±标准差）时间（分钟）：护士为6.8（±3.0），住院医师为10.4（±4.1），主治医生/专科住院医生为9.4（±4.3）。67%的蜂群式协作会诊包含电子病历记录，39%的会诊包含床边开具的医嘱。平均（±标准差）患者家属满意度为4.8（±0.7；李克特量表1 - 5）。
目前实施的蜂群式协作存在显著差异，但能提高医护人员和患者家属的满意度。医生们也一致认为，蜂群式协作可改善急诊环境下对实习医生的培训。急诊室的不可预测性以及观察到的实施差异凸显了蜂群式协作的益处和障碍。我们的研究结果为完善、规范和评估我们的蜂群式协作模式提供了关键基础。
