Impact of electronic health record implementation on patient flow metrics in a pediatric emergency department

Implementing electronic health records (EHR) in healthcare settings incurs challenges, none more important than maintaining efficiency and safety during rollout. This report quantifies the impact of offloading low-acuity visits to an alternative care site from the emergency department (ED) during EHR implementation. In addition, the report evaluated the effect of EHR implementation on overall patient length of stay (LOS), time to medical provider, and provider productivity during implementation of the EHR. Overall LOS and time to doctor increased during EHR implementation. On average, admitted patients' LOS was 6–20% longer. For discharged patients, LOS was 12–22% longer. Attempts to reduce patient volumes by diverting patients to another clinic were not effective in minimizing delays in care during this EHR implementation. Delays in ED throughput during EHR implementation are real and significant despite additional providers in the ED, and in this setting resolved by 3 months post-implementation

Impact of Scribes with Flow Coordination Duties on Throughput in an Academic Emergency Department

Introduction: With the increasing influence of electronic health records in emergency medicine came concerns of decreasing operational efficiencies. Particularly worrisome was increasing patient length of stay (LOS). Medical scribes were identified to be in a good position to quickly address barriers to treatment delivery and patient flow. The objective of this study was to investigate patient LOS in the mid- and low-acuity zones of an academic emergency department (ED) with and without medical scribes.Methods: A retrospective cohort study compared patient volume and average LOS between a cohort without scribes and a cohort after the implementation of a scribe-flow coordinator program. Patients were triaged to the mid-acuity Vertical Zone (primarily Emergency Severity Index [ESI] 3) or low-acuity Fast Track (primarily ESI 4 and 5) at a tertiary academic ED. Patients were stratified by treatment zone, acuity level, and disposition.Results: The pre-intervention and post-intervention periods included 8900 patients and 9935 patients, respectively. LOS for patients discharged from the Vertical Zone decreased by 12 minutes from 235 to 223 minutes (p<0.0001, 95% confidence interval [CI], -17,-7) despite a 10% increase in patient volume. For patients admitted from the Vertical Zone, volume increased 13% and LOS remained almost the same, increasing from 225 to 228 minutes (p=0.532, 95% CI, -6,12). For patients discharged from the Fast Track, volume increased 14% and LOS increased six minutes, from 89 to 95 minutes (p<0.0001, 95% CI, 4,9). Predictably, only 1% of Fast Track patients were admitted.Conclusion: Despite substantially increased volume, the use of scribes as patient flow facilitators in the mid-acuity zone was associated with decreased LOS. In the low-acuity zone, scribes were not shown to be as effective, perhaps because rapid patient turnover required them to focus on documentation

A novel streamlined trauma response team training improves imaging efficiency for pediatric blunt abdominal trauma patients

Background/purpose The morbidity and mortality of children with traumatic injuries are directly related to the time to definitive management of their injuries. Imaging studies are used in the trauma evaluation to determine the injury type and severity. The goal of this project is to determine if a formal streamlined trauma response improves efficiency in pediatric blunt trauma by evaluating time to acquisition of imaging studies and definitive management. Methods This study is a chart review of patients < 18 years who presented to a pediatric trauma center following blunt trauma requiring trauma team activation. 413 records were reviewed to determine if training changed the efficiency of CT acquisition and 652 were evaluated for FAST efficiency. The metrics used for comparison were time from ED arrival to CT image, FAST, and disposition. Results Time from arrival to CT acquisition decreased from 37 (SD 23) to 28 (SD27) min (p < 0.05) after implementation. The proportion of FAST scans increased from 315 (63.5%) to 337 (80.8%) and the time to FAST decreased from 18 (SD15) to 8 (SD10) min (p < 0.05). The time to operating room (OR) decreased after implementation. Conclusion The implementation of a streamlined trauma team approach is associated with both decreased time to CT, FAST, OR, and an increased proportion of FAST scans in the pediatric trauma evaluation. This could result in the rapid identification of injuries, faster disposition from the ED, and potentially improve outcomes in bluntly injured children

Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical Homes

Describes in detail eight change concepts as a guide to transforming a practice into a patient-centered medical home, including engaged leadership, quality improvement strategy, continuous and team-based healing relationships, and enhanced access

Efficacy and Safety of Pediatric Critical Care Physician Telemedicine Involvement in Rapid Response Team and Code Response in a Satellite Facility

OBJECTIVES: Satellite inpatient facilities of larger children's hospitals often do not have on-site intensivist support. In-house rapid response teams and code teams may be difficult to operationalize in such facilities. We developed a system using telemedicine to provide pediatric intensivist involvement in rapid response team and code teams at the satellite facility of our children's hospital. Herein, we compare this model with our in-person model at our main campus. DESIGN: Cross-sectional. SETTING: A tertiary pediatric center and its satellite facility. PATIENTS: Patients admitted to the satellite facility. INTERVENTIONS: Implementation of a rapid response team and code team model at a satellite facility using telemedicine to provide intensivist support. MEASUREMENTS AND MAIN RESULTS: We evaluated the success of the telemedicine model through three a priori outcomes: 1) reliability: involvement of intensivist on telemedicine rapid response teams and codes, 2) efficiency: time from rapid response team and code call until intensivist response, and 3) outcomes: disposition of telemedicine rapid response team or code calls. We compared each metric from our telemedicine model with our established main campus model. MAIN RESULTS: Critical care was involved in satellite campus rapid response team activations reliably (94.6% of the time). The process was efficient (median response time 7 min; mean 8.44 min) and effective (54.5 % patients transferred to PICU, similar to the 45-55% monthly rate at main campus). For code activations, the critical care telemedicine response rate was 100% (6/6), with a fast response time (median 1.5 min). We found no additional risk to patients, with no patients transferred from the satellite campus requiring a rapid escalation of care defined as initiation of vasoactive support, greater than 60 mL/kg in fluid resuscitation, or endotracheal intubation. CONCLUSIONS: Telemedicine can provide reliable, timely, and effective critical care involvement in rapid response team and Code Teams at satellite facilities

Improving provider compliance of the NAEPP 2007 asthma guidelines through the electronic health record (EHR) in a pediatric primary care practice

The Expert Panel Report -3 (EPR3) NAEPP 2007 evidence-based clinical asthma guidelines were developed to provide evidence-based high-quality patient care that leads to improved outcomes. A literature review showed that healthcare providers do not routinely follow the asthma guidelines. The purpose of this project was to develop and implement an evidence-based asthma electronic health record (EHR) template in a pediatric office to improve provider compliance to the guidelines resulting in improved outcomes for children with asthma. The study was conducted over a period of four months from January - April 2016. An EHR asthma protocol template and training for providers using a PACE program (physician asthma care education) on current guidelines was provided. A retrospective EHR audit measuring provider’s compliance was performed. Pre/post aggregate data for documentation specific to asthma was collected and analyzed using the chi square method. The outcome objectives from this quality improvement study focused on provider compliance and asthma control. Results indicated the EHR template significantly improved provider documentation in compliance with 7 of the 8 areas measured

Baystate Medical Practices Annual Report - 2017

https://scholarlycommons.libraryinfo.bhs.org/bmpannual_report/1001/thumbnail.jp

Reducing Delays in Follow-up Care through Process Optimization

Primary care follow-up after an emergency department (ED) visit is an important component of comprehensive healthcare, contributing to both improved patient outcomes and reduced readmissions to emergency care. In alignment with the Clinical Nurse Leader (CNL) roles of risk anticipator and lateral integrator of care, this project aimed to support improvement in care continuity for patients at a large primary care clinic in London. At this clinic, a team of physicians, nurses, and support staff care for a diverse population of adult and pediatric patients who account for nearly 3,000 ED visits annually. Assessment of the clinical review process used to coordinate post-emergency follow-up revealed that less than 22% of patients receive timely care and the process to initiate care takes an average 15 days to complete. To address this gap in quality and efficiency, an interprofessional team utilized root-cause analyses, process optimization, and small tests of change to develop an optimized clinical review process for post- emergency department follow-up care. Implementation of the process resulted in an 81.3% decrease in clinical review time and a 34.5% increase in on-time follow-up care. Process optimization is an effective framework through which rapid improvements in care processes can be implemented to enhance care quality and efficiency

Bronchiolitis in the Bluegrass: Epidemiology, Disease Burden and Resource Utilization at Kentucky Children’s Hospital

Background: Every year Kentucky Children’s Hospital (KCH) admits infants and toddlers with respiratory disease due to viral bronchiolitis. This disease is characterized by viral-induced inflammation and edema of the lower airways. The resulting disease is characterized by increasing mucus production, acute bronchospasm, necrosis of the respiratory epithelium and functional obstructive lung disease. Patients usually present with symptoms consistent with an upper respiratory tract infection, but can progress to marked respiratory distress and ultimately respiratory failure, as well as poor oral intake and dehydration. While Respiratory Syncytial Virus (RSV) is the pathogen classically described cause of viral bronchiolitis, other viruses have been known to cause this pathophysiology and symptoms. These viruses tend to cause disease during the colder months of the year, with a peak incidence between November and March. While there are no data regarding the disease burden for all viruses that can cause bronchiolitis, RSV infects approximately 90% of children in North America in the first two years of life with approximately half of those developing lower airway disease (Ralston, Lieberthal, & Meissner, 2015). In 2014, consensus clinical practice guidelines (CPG) regarding the outpatient and inpatient management of RSV bronchiolitis were published in Pediatrics. These guidelines were published with the goal of standardizing care across the spectrum of clinical environments and avoid unnecessary and unwarranted therapies. Currently, no specific treatment exists for this condition outside of supportive care, including invasive respiratory support ranging from supplemental oxygen to extracorporeal membrane oxygenation, IV hydration and airway clearance (Ralston et al., 2015). The medical literature describes a cohort of patients who are more likely to require Pediatric Intensive Care Unit (PICU) admission and support with PICU modalities, which increases the likelihood of complications related to medical care (Haataja, 2018). Objectives: The aim of this project was to quantify and categorize the disease burden associated with viral bronchiolitis at KCH. We examined all inpatient admissions of children ≤24 months to KCH with the diagnosis of viral bronchiolitis during two peak incidence seasons, defined as beginning November 1 and ending April 30. These admissions were evaluated based on the presence of significant co-morbid conditions and whether these conditions were associated with PICU admission. The project also assessed resource utilization across the inpatient hospital and determined which patients received no low-value treatments or diagnostics. These patients were defined as having received optimal care. The study also examined high flow nasal cannula (HFNC) utilization across the inpatient ward and PICU, including number of cases at KCH, number of transfers to the PICU and number of patients requiring immediate escalation or de-escalation in care. Results: A total of 601 admissions for viral bronchiolitis were identified between the dates of peak incidence season, including 281 admissions between November 1, 2016 and April 30, 2017 as well as 320 admissions between November 1, 2017 and April 30, 2018. A total of 186 admissions were identified in which the patient had a history of prematurity and 37 admissions 4 in which the patient had congenital heart disease (CHD). Other co-morbidities like neuromuscular disease, immunodeficiency and tracheostomy with or without chronic mechanical ventilation were identified only in small numbers. The mean age at admission was 6.37 months (median 3.75 months) old with a median admission weight of 6.5 kg. The age and weight distribution was skewed towards younger patients. Average length of stay was 100.43 hours with an overall cost of almost $3.9 million to the institution for all admissions. Most admissions come through the KCH Pediatric Emergency Department (PED) but a larger proportion of patients came to KCH via transfers from community hospitals within the region. Bronchiolitis appeared to drive hospital capacity in the first four months of the season but appeared to contribute less in March and April. Prematurity and CHD were associated with Pediatric Intensive Care Unit (PICU) admission (p=0.003, p=0.032) and higher total hospital costs (p=0.012, p=0.028). Premature patients had a higher overall utilization of bronchodilator therapy (p\u3c0.001), systemic corticosteroids (p\u3c0.001), radiograph utilization (p=0.015) and viral testing (p=0.007) but no significant differences in antibiotic use compared to the rest of the patients (p=0.705). Patient with CHD had a higher overall utilization of bronchodilators (p=0.007), radiograph utilization (p=0.001) and viral testing (p\u3c0.001) with no significant differences in antibiotic use (p=0.61) or corticosteroid use (p=0.051) compared with the rest of the patients. Utilization overall was more likely for PICU patients in all five metrics. Patients with no co-morbid conditions were considered to be optimal care candidates with patients who received no diagnostic and therapeutic intervention were considered to have received optimal care. Utilization in optimal care candidates versus patients who were not candidates from optimal care was significantly different in every metric except antibiotics among the 2017-18 cohort and not significantly different in every metric among the 2016-17 cohort. The proportion of patients who received optimal care increased from 32.1% in 2016-17 to 34.7% in 2017-18. A total of 167 admissions were placed on the therapy, of which 106 were started on HFNC on the inpatient ward and 60 in the PICU. Of those started on HFNC on the inpatient ward, transfers to the PICU decreased from 65% in 2016-17 to 41% in 2017-18. Of the 51 patients transferred to the PICU, seven (13.7%) were transferred back to the ward within 24 hours, six (11.7%) were escalated to non-invasive positive pressure ventilation (NIPPV) within 12 hours and another five (9.8%) were intubated and placed on mechanical ventilation within 12 hours. Discussion and Conclusions: This analysis suggests that most of the utilization of resources and costs associated with inpatient care for bronchiolitis are diverted towards patients with significant co-morbid conditions and patients who require PICU admission. The ultimate goal will be to reduce resource utilization among optimal care patients and increase the proportion of patients needing fewer interventions. This will include annual data collection prospectively for each peak incidence season and an annual scorecard to present at institutional quality and safety (Q&S) meetings. A KCH respiratory work group has been formed to help create educational materials for KCH providers and staff on the correct assessment of an infant or toddler with respiratory distress as well as a review of the recent CPG. The work group will also provide outreach education to community and rural healthcare providers who may have limited experience in the care of pediatric patients. Data from county of origin will help direct this education to areas that send a larger volume of patients with bronchiolitis to KCH in order to 5 optimize the impact. Multiple peak incidence seasons of inpatient data will help inform the creation of a new bronchiolitis protocol to guide inpatient management at KCH. HFNC data will continue to be collected during future peak incidence seasons in order to identify patient escalations, limit unnecessary transfers of patients to the PICU, and determine how KCH can best manage patients on HFNC outside of the PICU. The work group will also revise an existing HFNC management protocol in line with recent medical literature. Lastly, the work group will incorporate the KCH Pediatric Emergency Department (PED) and outpatient pediatric clinics in order to create an integrated project that spans the entire continuum of care. The project also fills a critical role in promoting best practices not only in the hospital, but within the community. KCH can play a leading role in promoting a competent, educated workforce both in the hospital and in the community. The hospital can also use the data to identify deficiencies both within the hospital and in the rural areas of Kentucky and create strategies to address them