Defining and Measuring Successful Emergency Care Networks: A Research Agenda

The demands on emergency services have grown relentlessly, and the Institute of Medicine (IOM) has asserted the need for “regionalized, coordinated, and accountable emergency care systems throughout the country.” There are large gaps in the evidence base needed to fix the problem of how emergency care is organized and delivered, and science is urgently needed to define and measure success in the emerging network of emergency care. In 2010, Academic Emergency Medicine convened a consensus conference entitled “Beyond Regionalization: Integrated Networks of Emergency Care.” This article is a product of the conference breakout session on “Defining and Measuring Successful Networks”; it explores the concept of integrated emergency care delivery and prioritizes a research agenda for how to best define and measure successful networks of emergency care. The authors discuss five key areas: 1) the fundamental metrics that are needed to measure networks across time-sensitive and non–time-sensitive conditions; 2) how networks can be scalable and nimble and can be creative in terms of best practices; 3) the potential unintended consequences of networks of emergency care; 4) the development of large-scale, yet feasible, network data systems; and 5) the linkage of data systems across the disease course. These knowledge gaps must be filled to improve the quality and efficiency of emergency care and to fulfill the IOM’s vision of regionalized, coordinated, and accountable emergency care systems. ACADEMIC EMERGENCY MEDICINE 2010; 17:1297–1305 © 2010 by the Society for Academic Emergency Medicine     

The NICU Graduate: Implications for Pediatric Primary Care

Mortality rates of extremely preterm infants continue to decline as neonatal technology and care improve. Following graduation from the Neonatal Intensive Care Unit, preterm infants will transition to pediatric primary care offices for continued care and treatment. These infants often have complex health care needs that present inherent challenges to the pediatric health care providers who will provide that ongoing care. Implications for primary care providers include knowledge and treatment modalities of the common complications of the preterm infant. These complications typically include chronic lung disease; catch up growth and additional nutritional needs, neurodevelopmental monitoring, feeding challenges, retinopathy of prematurity and apnea of prematurity. Each patient–parent dyad will need a customized approach to primary care, coordinating care with physical, occupational, and speech therapy as well as other specialist in order to accomplish the best long term outcomes. Strategies for success in meeting the health care needs of infants and families following transition from the Neonatal Intensive Care Unit to primary care are provided.     

Entropy: A Conceptual Approach to Measuring Situation-level Workload Within Emergency Care and its Relationship to Emergency Department Crowding

Background

Emergency department (ED) crowding correlates with patient safety. Difficulties quantifying crowding and providing solutions were highlighted in the recent Institute of Medicine (IOM) report calling for the application of advanced industrial engineering (IE) research techniques to evaluate ED crowding. ED personnel workload is a related concept, with potential reciprocal effects between the two. Collaboration between emergency medicine and IE is needed to address crowding and ED personnel workload.

Objective

We review ED crowding and workload literature, relationships between workload and ED crowding, and the potential application of information theory as implemented in IE frameworks entitled “entropy” in evaluating both topics.

Discussion

IE techniques have applications for emergency medicine and have been successful in helping improve ED operations. Lean and Six Sigma applications are some of these techniques. Existing ED workload measures don't account for all aspects of work in the ED (acuity, efficiency, tasks, etc.) Crowding scales, such as NEDOCS (National ED Overcrowding Study) and EDWIN (ED Work Index), fail to predict ED crowding. A new measurement “entropy” may provide a more comprehensive evaluation of ED workload and may predict work overload seen with crowding. Entropy measures task-based work and the information flow involved. By assigning an entropy value to patient type-specific tasks, we might predict when the ED is overwhelmed, and crowded.

Conclusions

IE techniques provide solutions to the ED crowding problem and improve ED workload. We propose a technique novel to medicine: “Entropy,” derived from information theory, which may provide insight into ED personnel workload, its potential for measuring ED crowding, and possibly, in predicting an overwhelming situation.     

Testing Alertness of Emergency Physicians: A Novel Quantitative Measure of Alertness and Implications for Worker and Patient Care

BackgroundEstablishing practical solutions to manage fatigue in health care settings could reduce errors. Predictive Safety SRP Inc.’s AlertMeter is a 2-min cognitive assessment tool currently used in high-hazard industries to identify fatigued staff.ObjectiveNo prior study has attempted to address fatigue in emergency medicine (EM). We objectively assessed provider alertness to determine potential application of software-based fatigue recognition for risk reduction.MethodsIn a double-blind, prospective evaluation from July 1 to September 30, 2016, we applied the AlertMeter to EM residents at an academic level I trauma center. The tool was applied before and after shifts to evaluate alertness in three types of shifts: day, evening, and night. All residents were invited to participate—27 of 30 enrolled. Analysis of covariance (ANCOVA) was implemented to examine shift and completion effects on alertness score using baseline score as a covariate. Additionally, three separate ANCOVAs were conducted to examine alertness score differences between portion (start vs. end) and type of shift (day, evening, or night).ResultsResidents were significantly less alert at the completion of the evening shift. Scores at the end of the night shift were significantly lower than the start of the night shift.ConclusionsAlertness software can be reliably integrated into the emergency department. Alertness was lower at the end of the evening shift and end of the night shift. This work could have positive implications on shift and task scheduling and potentially reduce errors in patient care by quantifying providers’ fatigue and identifying areas for countermeasures.     

The Surrey Emergency Care System: a countywide initiative for change

Modernisation is at the core of government policy. Within the NHS it has variously focused on accident and emergency, coronary heart disease, clinical governance and information technology although each strand has tended to operate in isolation. The Surrey Emergency Care System is a programme combining the strands into a single countywide initiative and that lays the technical and clinical foundations of a future integrated unscheduled care network. This paper describes the programme, its potential impact, and offers some insight into the barriers to change that the project has met so far.     

Emergency Newborn Care: The First Moments of Life

Abstract

Objective. Drowning is associated with a high mortality and morbidity and a common cause of death. In-water resuscitation (IWR) in the case of drowning accidents has been recommended by certain resuscitation guidelines in the last several years. IWR has been discussed controversially in the past, especially with regard to the delay of chest compressions, effectiveness of ventilation, and hazard to the rescuer. The aim of the present study was to assess the effectiveness and safety of IWR. Methods. In this crossover manikin study, 21 lifeguards and 21 laypersons performed two rescue procedures in an indoor swimming pool over a 50-meter distance: In random order, one rescue procedure was performed with in-water ventilation and one without. Tidal and minute volumes were recorded using a modified Laerdal Resusci Anne (Laerdal Medical, Stavanger, Norway) and total rescue duration, submersions, water aspiration by the victim, and physical effort were assessed. Results. IWR resulted in significant increases in rescue duration (lifeguards: 106 vs. 82 seconds; laypersons: 133 vs. 106 seconds) and submersions (lifeguards: 3 vs. 1; laypersons: 5 vs. 0). Furthermore, water aspiration (lifeguards: 112 vs. 29 mL; laypersons: 160 vs. 56 mL) and physical effort (lifeguards: visual analog scale [VAS] score 7 vs. 5; laypersons: VAS score 8 vs. 6) increased significantly when IWR was performed. Lifeguards achieved significantly better ventilation characteristics and performed both rescue procedures faster and with lower side effects. IWR performed by laypersons was insufficient with regard to both tidal and minute volumes. Conclusions. In-water resuscitation is associated with a delay of the rescue procedure and a relevant aspiration of water by the victim. IWR appears to be possible when performed over a short distance by well-trained professionals. The training of lifeguards must place particular emphasis on a reduction of submersions and aspiration when IWR is performed. IWR by laypersons is exhausting, time-consuming, and inefficient and should probably not be recommended.