Contrasting treatment and outcomes of septic shock: presentation on hospital floors versus emergency department

Background Patients with septic shock have a high mortality. This study used the Surviving Sepsis Campaign （SSC）database to compare characteristics, treatments and outcomes of septic shock patients diagnosed in the emergency department （ED） to patients developing septic shock on hospital floors （HF）.Methods The studied population included patients admitted to the intensive care unit （ICU） of an urban tertiary care medical center over an 18-month period. Acute physiology and chronic health evaluation （APACHE Ⅱ） scores, need for mechanical ventilation （MV）, performance on four of the SSC resuscitation bundle indicators, ICU length of stay （LOS）,hospital LOS and in-hospital mortality were ascertained.Results Sixty-six ED and 27 HF septic shock patients were included in this study. Urinary tract infections （UTI） and pneumonia were the two most common sites of infection in the ED patients. The sources of infection for HF septic shock patients were fairly well distributed across etiologies. The time to achieve superior vena cava oxygen saturation （ScvO2）＞ 70% in HF patients （（10.8±9.1） hours） was longer when compared to the ED patients （（6.6±-6.1） hours） （P ＜0.05）.Hospital mortality for the ED and HF patients were 25.8% and 59.3%, respectively （P ＜0.05）. Use of MV during the first 24 hours of shock was 44% in the ED patients and 70% in the HF patients （P ＜0.05） and was linked to mortality.Conclusions When compared to HF patients, ED septic shock patients have lower in-hospital mortality, there was less use of MV during the first 24 hours following onset of septic shock and the HF patients required a longer time to achieve target ScvO2. The need for mechanical ventilation is independently associated with increased mortality.     

The access-block effect: relationship between delay to reaching an inpatient bed and inpatient length of stay

OBJECTIVES: To investigate the relationship between access block in the emergency department (ED) (defined as total time from arrival to transfer from the ED over eight hours) and inpatient length of stay (LOS). DESIGN AND SETTING: Retrospective cohort study of all admissions through the ED to a tertiary hospital in Canberra, Australian Capital Territory, during 1999. MAIN OUTCOME MEASURES: Total time in the ED and LOS, calculated in days from ED departure to hospital discharge (non-overnight admissions were assigned LOS of one day, and all LOS were truncated at 10 days). RESULTS: 11 906 admissions were included, and 919 experienced access block (7.7%). Mean LOS was 4.9 days in those who experienced access block (95% CI, 4.7-5.1), compared with 4.1 days in the no-block group (95% CI, 4.0-4.2; P < 0.0001). Subgroup analysis showed that this "access block effect" occurred across different severities of illness and diagnoses. A strong relationship was found between longer LOS and arrival of access-block patients on the inpatient ward outside office hours (0800-1600 weekdays). CONCLUSIONS: This is the first study to show an association between access block and a measure of outcome outside the ED. If the effect of access block on LOS is reproduced in other settings, there are major implications for hospital management.     

Exploring the relationship between electronic health records and provider burnout: A systematic review

ObjectiveStress and burnout due to electronic health record (EHR) technology has become a focus for burnout intervention. The aim of this study is to systematically review the relationship between EHR use and provider burnout.Materials and MethodsA systematic literature search was performed on PubMed, EMBASE, PsychInfo, ACM Digital Library in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Inclusion criterion was original research investigating the association between EHR and provider burnout. Studies that did not measure the association objectively were excluded. Study quality was assessed using the Medical Education Research Study Quality Instrument. Qualitative synthesis was also performed.ResultsTwenty-six studies met inclusion criteria. The median sample size of providers was 810 (total 20 885; 44% male; mean age 53 [range, 34-56] years). Twenty-three (88%) studies were cross-sectional studies and 3 were single-arm cohort studies measuring pre- and postintervention burnout prevalence. Burnout was assessed objectively with various validated instruments. Insufficient time for documentation (odds ratio [OR], 1.40-5.83), high inbox or patient call message volumes (OR, 2.06-6.17), and negative perceptions of EHR by providers (OR, 2.17-2.44) were the 3 most cited EHR-related factors associated with higher rates of provider burnout that was assessed objectively.ConclusionsThe included studies were mostly observational studies; thus, we were not able to determine a causal relationship. Currently, there are few studies that objectively assessed the relationship between EHR use and provider burnout. The 3 most cited EHR factors associated with burnout were confirmed and should be the focus of efforts to improve EHR-related provider burnout.     

How is the electronic health record being used? Use of EHR data to assess physician-level variability in technology use

Background

Studies of the effects of electronic health records (EHRs) have had mixed findings, which may be attributable to unmeasured confounders such as individual variability in use of EHR features.

Objective

To capture physician-level variations in use of EHR features, associations with other predictors, and usage intensity over time.

Methods

Retrospective cohort study of primary care providers eligible for meaningful use at a network of federally qualified health centers, using commercial EHR data from January 2010 through June 2013, a period during which the organization was preparing for and in the early stages of meaningful use.

Results

Data were analyzed for 112 physicians and nurse practitioners, consisting of 430 803 encounters with 99 649 patients. EHR usage metrics were developed to capture how providers accessed and added to patient data (eg, problem list updates), used clinical decision support (eg, responses to alerts), communicated (eg, printing after-visit summaries), and used panel management options (eg, viewed panel reports). Provider-level variability was high: for example, the annual average proportion of encounters with problem lists updated ranged from 5% to 60% per provider. Some metrics were associated with provider, patient, or encounter characteristics. For example, problem list updates were more likely for new patients than established ones, and alert acceptance was negatively correlated with alert frequency.

Conclusions

Providers using the same EHR developed personalized patterns of use of EHR features. We conclude that physician-level usage of EHR features may be a valuable additional predictor in research on the effects of EHRs on healthcare quality and costs.     

Visualizing collaborative electronic health record usage for hospitalized patients with heart failure

Objective To visualize and describe collaborative electronic health record (EHR) usage for hospitalized patients with heart failure.Materials and methods We identified records of patients with heart failure and all associated healthcare provider record usage through queries of the Northwestern Medicine Enterprise Data Warehouse. We constructed a network by equating access and updates of a patient’s EHR to a provider-patient interaction. We then considered shared patient record access as the basis for a second network that we termed the provider collaboration network. We calculated network statistics, the modularity of provider interactions, and provider cliques.Results We identified 548 patient records accessed by 5113 healthcare providers in 2012. The provider collaboration network had 1504 nodes and 83 998 edges. We identified 7 major provider collaboration modules. Average clique size was 87.9 providers. We used a graph database to demonstrate an ad hoc query of our provider-patient network.Discussion Our analysis suggests a large number of healthcare providers across a wide variety of professions access records of patients with heart failure during their hospital stay. This shared record access tends to take place not only in a pairwise manner but also among large groups of providers.Conclusion EHRs encode valuable interactions, implicitly or explicitly, between patients and providers. Network analysis provided strong evidence of multidisciplinary record access of patients with heart failure across teams of 100+ providers. Further investigation may lead to clearer understanding of how record access information can be used to strategically guide care coordination for patients hospitalized for heart failure.     

Process Modeling of Emergency Department Patient Flow: Effect of Patient Length of Stay on ED Diversion

A discreet event simulation methodology has been used to establish a quantitative relationship between Emergency Department (ED) performance characteristics, such as percent of time on ambulance diversion and the number of patients in queue in the waiting room, and the upper limits of patient length of stay (LOS). A simulation process model of ED patient flow has been developed that took into account a significant difference between LOS distributions of patients discharged home and patients admitted into the hospital. Using simulation model it has been identified that ED diversion could be negligible (less than ∼0.5%) if patients discharged home stay in ED not more than 5 h, and patients admitted into the hospital stay in ED not more than 6 h Using full factorial design of experiments with two factors and the model’s predicted percent diversion as a response function, other combinations of LOS upper limits have been determined that would result in low ED percent diversion as well. It has also been determined that if the number of patients exceeds 11 in queue in ED waiting room then the diversion percent is rapidly increasing.     

Cost-Effectiveness Evaluation of EHR: Simulation of an Abdominal Aortic Aneurysm in the Emergency Department

Health care organizations have installed electronic systems to increase efficiency in health care. Empirically assessing the cost-effectiveness of technologies to the health care system is a challenging and complex task. This study examined cost-effectiveness of additional clinical information supplied via an EHR system by simulating a case of abdominal aortic aneurysm devised and acted professionally by the Israel Center of Medical Simulation. We conducted a simulation-based study on physicians who were asked to treat a simulated patient for the prevalent medical scenario of hip and leg pain that actually corresponded to an abdominal aortic aneurysm. Half of the participating physicians from the Department of Emergency Medicine at Tel-Hashomer Hospital – Israel’s largest - had access to an EHR system that integrates medical data from multiple health providers (community and hospitals) in addition to the local health record, and half did not. To model medical decision making, the results of the simulation were combined with a Markov Model within a decision tree. Cost-effectiveness was analyzed by comparing the effects of the admission/discharge decision in units of quality adjusted life years (QALYs) to the estimated costs. The results showed that using EHR in the ED increases the QALY of the patient and improves medical decision-making. The expenditure per patient for one QALY unit as a result of using the EHR was $1229, which is very cost-effective according to many accepted threshold values (less than all these values). Thus, using the EHR contributes to making a cost-effective decision in this specific but prevalent case.     

The impact of an electronic health record on nurse sensitive patient outcomes: an interrupted time series analysis

Objectives

To evaluate the impact of electronic health record (EHR) implementation on nursing care processes and outcomes.

Design

Interrupted time series analysis, 2003–2009.

Setting

A large US not-for-profit integrated health care organization.

Participants

29 hospitals in Northern and Southern California.

Intervention

An integrated EHR including computerized physician order entry, nursing documentation, risk assessment tools, and documentation tools.

Main outcome measures

Percentage of patients with completed risk assessments for hospital acquired pressure ulcers (HAPUs) and falls (process measures) and rates of HAPU and falls (outcome measures).

Results

EHR implementation was significantly associated with an increase in documentation rates for HAPU risk (coefficient 2.21, 95% CI 0.67 to 3.75); the increase for fall risk was not statistically significant (0.36; −3.58 to 4.30). EHR implementation was associated with a 13% decrease in HAPU rates (coefficient −0.76, 95% CI −1.37 to −0.16) but no decrease in fall rates (−0.091; −0.29 to 0.11). Irrespective of EHR implementation, HAPU rates decreased significantly over time (−0.16; −0.20 to −0.13), while fall rates did not (0.0052; −0.01 to 0.02). Hospital region was a significant predictor of variation for both HAPU (0.72; 0.30 to 1.14) and fall rates (0.57; 0.41 to 0.72).

Conclusions

The introduction of an integrated EHR was associated with a reduction in the number of HAPUs but not in patient fall rates. Other factors, such as changes over time and hospital region, were also associated with variation in outcomes. The findings suggest that EHR impact on nursing care processes and outcomes is dependent on a number of factors that should be further explored.     

Evaluating the effectiveness of evidence-based guidelines for the use of spacer devices in children with acute asthma

OBJECTIVE: To change standard practice from using nebulisers to metered dose inhalers and holding chambers (spacers) in children presenting with mild to moderate acute asthma. DESIGN: A before-after comparison of children with acute asthma presenting to the emergency department (ED) between August and October 1999 with those presenting between June and August 1997. SETTING: A tertiary care metropolitan children's hospital. INTERVENTIONS: Evidence-based clinical practice guidelines for using spacers were developed by a local multidisciplinary consensus process. A multifaceted guideline implementation program was used in 1999. MAIN OUTCOME MEASURES: Physician prescribing practices (spacer use); clinical outcomes (need for hospitalisation, admission to intensive care unit, and length of stay [LOS]). RESULTS: 75 of 247 children (30%; 95% CI, 25%-36%) required hospital admission in 1999. This was similar to the 1997 study period, when 95 of 326 (29%; 95% CI, 24%-34%) children were admitted. Of those with mild to moderate asthma, 160 (68%) received bronchodilators in the ED; 151 (94%) were initially treated with a spacer device in 1999. In 1997, no children were initially treated with spacers in the ED. The median (range) LOS in hospital for children with asthma of all severities was 1.7 (0.5-19.8) days in 1999 and 1.7 (0.2-7.6) days in 1997 (P=0.85). CONCLUSIONS: We successfully changed standard practice from using nebulisers to spacers for bronchodilator delivery in children with mild to moderate acute asthma, with no difference in the need for or duration of hospitalisation.     

A novel application of SMART on FHIR architecture for interoperable and scalable integration of patient-reported outcome data with electronic health records

ObjectiveDespite a proliferation of applications (apps) to conveniently collect patient-reported outcomes (PROs) from patients, PRO data are yet to be seamlessly integrated with electronic health records (EHRs) in a way that improves interoperability and scalability. We applied the newly created PRO standards from the Office of the National Coordinator for Health Information Technology to facilitate the collection and integration of standardized PRO data. A novel multitiered architecture was created to enable seamless integration of PRO data via Substitutable Medical Apps and Reusable Technologies on Fast Healthcare Interoperability Resources apps and scaled to different EHR platforms in multiple ambulatory settings.Materials and MethodsWe used a standards-based approach to deploy 2 apps that source and surface PRO data in real-time for provider use within the EHR and which rely on PRO assessments from an external center to streamline app and EHR integration.ResultsThe apps were developed to enable patients to answer validated assessments (eg, a Patient-Reported Outcomes Measurement Information System including using a Computer Adaptive Test format). Both apps were developed to populate the EHR in real time using the Health Level Seven FHIR standard allowing providers to view patients’ data during the clinical encounter. The process of implementing this architecture with 2 different apps across 18 ambulatory care sites and 3 different EHR platforms is described.ConclusionOur approach and solution proved feasible, secure, and time- and resource-efficient. We offer actionable guidance for this technology to be scaled and adapted to promote adoption in diverse ambulatory care settings and across different EHRs.     

Electronic Health Records in Specialty Care: A Time-Motion Study

BackgroundElectronic health records (EHRs) have great potential to improve safety, quality, and efficiency in medicine. However, adoption has been slow, and a key concern has been that clinicians will require more time to complete their work using EHRs. Most previous studies addressing this issue have been done in primary care.ObjectiveTo assess the impact of using an EHR on specialists’ time.DesignProspective, before-after trial of the impact of an EHR on attending physician time in four specialty clinics at an integrated delivery system: cardiology, dermatology, endocrine, and pain.MeasurementsWe used a time-motion method to measure physician time spent in one of 85 designated activities.ResultsAttending physicians were monitored before and after the switch from paper records to a web-based ambulatory EHR. Across all specialties, 15 physicians were observed treating 157 patients while still using paper-based records, and 15 physicians were observed treating 146 patients after adoption. Following EHR implementation, the average adjusted total time spent per patient across all specialties increased slightly but not significantly (Δ = 0.94 min., p = 0.83) from 28.8 (SE = 3.6) to 29.8 (SE = 3.6) min.ConclusionThese data suggest that implementation of an EHR had little effect on overall visit time in specialty clinics.     

西部农村急性心肌梗死患者住院时长及其影响因素分析

目的 了解我国西部农村地区急性心肌梗死（AMI）患者平均住院时长情况和变化趋势,探索与平均住院时长有关的医院水平影响因素。方法 通过随机抽样收集我国西部农村地区9省份30家医院2001、2006、2011年的AMI住院患者病历资料,将纳入研究的医院按照住院时间的中位数划分为3类。采用针对整群数据的卡方检验或方差分析对3类医院患者特征差异进行检验,采用Mann-Kendall法检验住院时长在3个研究年份的变化趋势。采用多因素广义线性模型检验医院特征对住院时长的影响。结果 本研究最终共纳入814份病历。3类医院所入选的AMI患者的入院时间、肾小球滤过率存在显著差异(P＜0.05)。2001、2006及2011年的平均住院时长分别为（14.6±16.6）、（11.6±8.7）和（12.2±7.4）d,各年份间无显著的变化趋势（P=0.50）。调整患者水平特征后的无并发症病例分析结果显示,3个年份的平均住院时长分别为（11.1±8.3）、（10.9±6.9）和（11.6±5.7）d,各年份间仍无显著的变化趋势（P=0.68）。非附属非教学医院的患者平均住院时长较长,增加约6 d（95%CI：1.58～10.19）,未开展冠脉造影医院的患者平均住院时长增加约3.7d（95%CI：0.46～6.99）。结论 我国西部农村地区医院AMI住院患者的平均住院时长仍不理想。2001~2011年平均住院时长无显著改善,进一步提高临床诊疗能力,缩短住院时长是改善我国西部农村地区AMI患者诊疗的关键。     

ICU nurses' acceptance of electronic health records

Objective

To assess intensive care unit (ICU) nurses'' acceptance of electronic health records (EHR) technology and examine the relationship between EHR design, implementation factors, and nurse acceptance.

Design

The authors analyzed data from two cross-sectional survey questionnaires distributed to nurses working in four ICUs at a northeastern US regional medical center, 3 months and 12 months after EHR implementation.

Measurements

Survey items were drawn from established instruments used to measure EHR acceptance and usability, and the usefulness of three EHR functionalities, specifically computerized provider order entry (CPOE), the electronic medication administration record (eMAR), and a nursing documentation flowsheet.

Results

On average, ICU nurses were more accepting of the EHR at 12 months as compared to 3 months. They also perceived the EHR as being more usable and both CPOE and eMAR as being more useful. Multivariate hierarchical modeling indicated that EHR usability and CPOE usefulness predicted EHR acceptance at both 3 and 12 months. At 3 months postimplementation, eMAR usefulness predicted EHR acceptance, but its effect disappeared at 12 months. Nursing flowsheet usefulness predicted EHR acceptance but only at 12 months.

Conclusion

As the push toward implementation of EHR technology continues, more hospitals will face issues related to acceptance of EHR technology by staff caring for critically ill patients. This research suggests that factors related to technology design have strong effects on acceptance, even 1 year following the EHR implementation.     

Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes

BackgroundThe 21st Century Cures Act mandates patients’ access to their electronic health record (EHR) notes. To our knowledge, no previous work has systematically invited patients to proactively report diagnostic concerns while documenting and tracking their diagnostic experiences through EHR-based clinician note review.ObjectiveTo test if patients can identify concerns about their diagnosis through structured evaluation of their online visit notes.MethodsIn a large integrated health system, patients aged 18–85 years actively using the patient portal and seen between October 2019 and February 2020 were invited to respond to an online questionnaire if an EHR algorithm detected any recent unexpected return visit following an initial primary care consultation (“at-risk” visit). We developed and tested an instrument (Safer Dx Patient Instrument) to help patients identify concerns related to several dimensions of the diagnostic process based on notes review and recall of recent “at-risk” visits. Additional questions assessed patients’ trust in their providers and their general feelings about the visit. The primary outcome was a self-reported diagnostic concern. Multivariate logistic regression tested whether the primary outcome was predicted by instrument variables.ResultsOf 293 566 visits, the algorithm identified 1282 eligible patients, of whom 486 responded. After applying exclusion criteria, 418 patients were included in the analysis. Fifty-one patients (12.2%) identified a diagnostic concern. Patients were more likely to report a concern if they disagreed with statements “the care plan the provider developed for me addressed all my medical concerns” [odds ratio (OR), 2.65; 95% confidence interval [CI], 1.45–4.87) and “I trust the provider that I saw during my visit” (OR, 2.10; 95% CI, 1.19–3.71) and agreed with the statement “I did not have a good feeling about my visit” (OR, 1.48; 95% CI, 1.09–2.01).ConclusionPatients can identify diagnostic concerns based on a proactive online structured evaluation of visit notes. This surveillance strategy could potentially improve transparency in the diagnostic process.     

Implementation and Use of an Electronic Health Record within the Indian Health Service

Objectives

There are limited data regarding implementing electronic health records (EHR) in underserved settings. We evaluated the implementation of an EHR within the Indian Health Service (IHS), a federally funded health system for Native Americans.

Design

We surveyed 223 primary care clinicians practicing at 26 IHS health centers that implemented an EHR between 2003 and 2005.

Methods

The survey instrument assessed clinician attitudes regarding EHR implementation, current utilization of individual EHR functions, and attitudes regarding the use of information technology to improve quality of care in underserved settings. We fit a multivariable logistic regression model to identify correlates of increased utilization of the EHR.

Results

The overall response rate was 56%. Of responding clinicians, 66% felt that the EHR implementation process was positive. One-third (35%) believed that the EHR improved overall quality of care, with many (39%) feeling that it decreased the quality of the patient–doctor interaction. One-third of clinicians (34%) reported consistent use of electronic reminders, and self-report that EHRs improve quality was strongly associated with increased utilization of the EHR (odds ratio 3.03, 95% confidence interval 1.05–8.8). The majority (87%) of clinicians felt that information technology could potentially improve quality of care in rural and underserved settings through the use of tools such as online information sources, telemedicine programs, and electronic health records.

Conclusions

Clinicians support the use of information technology to improve quality in underserved settings, but many felt that it was not currently fulfilling its potential in the IHS, potentially due to limited use of key functions within the EHR.     

Practice and market factors associated with provider volume of health information exchange

ObjectiveTo assess the practice- and market-level factors associated with the amount of provider health information exchange (HIE) use.Materials and MethodsProvider and practice-level data was drawn from the Meaningful Use Stage 2 Public Use Files from the Centers for Medicare and Medicaid Services, the Physician Compare National Downloadable File, and the Compendium of US Health Systems, among other sources. We analyzed the relationship between provider HIE use and practice and market factors using multivariable linear regression and compared primary care providers (PCPs) to non-PCPs. Provider volume of HIE use is measured as the percentage of referrals sent with electronic summaries of care (eSCR) reported by eligible providers attesting to the Meaningful Use electronic health record (EHR) incentive program in 2016.ResultsProviders used HIE in 49% of referrals; PCPs used HIE in fewer referrals (43%) than non-PCPs (57%). Provider use of products from EHR vendors was negatively related to HIE use, while use of Athenahealth and Greenway Health products were positively related to HIE use. Providers treating, on average, older patients and greater proportions of patients with diabetes used HIE for more referrals. Health system membership, market concentration, and state HIE consent policy were unrelated to provider HIE use.DiscussionHIE use during referrals is low among office-based providers with the capability for exchange, especially PCPs. Practice-level factors were more commonly associated with greater levels of HIE use than market-level factors.ConclusionThis furthers the understanding that market forces, like competition, may be related to HIE adoption decisions but are less important for use once adoption has occurred.