Improvement of Procedure Documentation Compliance With the Implementation of a Visual Aid.

BACKGROUND: Emergency department (ED) providers face increasing task burdens and requirements related to documentation and paperwork. To decrease the mental task burden for providers, our institution developed an infographic that illustrates which forms are necessary for complete documentation of nonemergent invasive procedures. OBJECTIVES: Our study aims to analyze the effect of a nonelectronic health record-based infographic, paired with direct feedback, on compliance with nonemergent invasive procedure documentation performed in the ED. METHODS: This was a retrospective, observational study of all procedure documentation performed in the ED with a pre-/post-test design. The study included two 8-month study periods, 1 year apart. The preimplementation period used for comparison was January 1, 2019-August 31, 2019, and the postimplementation period was January 1, 2020-August 31, 2020. All invasive procedures that required documentation in addition to a procedure note were included in the study. The primary outcome was the percentage of compliance with documentation requirements. RESULTS: During the pre- and postimplementation study periods, 486 and 405 charts with nonemergent procedures were identified, respectively. In the preimplementation period, 278 (57%) procedures were compliant with all documentation, vs. the postimplementation period, where 287 (71%) procedures were compliant (p < 0.001). CONCLUSION: Implementing an invasive procedure documentation infographic and direct feedback improved overall documentation compliance for nonemergent invasive procedures.

The effect of practice settings on individual Doctor Press Ganey scores: A retrospective cohort review.

OBJECTIVE: The Press Ganey (PG) survey is a patient experience survey mailed to patients upon discharge from the emergency department (ED). It is a nationally recognized survey that is commonly used to measure patient's perception of the healthcare delivered. Emergency medicine physicians at Staten Island University Hospital staff two distinct sites: a tertiary-care setting (SIUH-N) and a community setting (SIUH-S). The goal of our study was to compare the effect of different ED practice settings, within the same hospital and healthcare system, on individual attending physician PG scores. METHODS: This was a retrospective, observational study of EM physicians, conducted at Staten Island University Hospital between January 1, 2015 and December 31, 2016. Physicians with PG survey responses from both sites were included. The number of responses and mean scores for the four doctor specific survey questions and the doctor overall score were extracted from PG surveys. RESULTS: Mean PG scores at SIUH-N were significantly lower than the mean scores at SIUH-S in each of the four doctor-specific questions, as well as the doctor overall score (p < 0.05). 16 out of 18 doctors demonstrated higher doctor overall scores at SIUH-S. CONCLUSION: Variables other than the individual doctor may be influencing the PG survey responses and perceptions of care. The PG survey may underestimate the impact of different practice settings on individual doctor PG scores.

Femoral nerve blocks versus standard pain control for hip fractures: a retrospective comparative analysis.

OBJECTIVE: Pain control for hip fractures is often achieved via intravenous opioids. However, opioids can have dangerous adverse effects, including respiratory depression and delirium. Peripheral nerve blockade is an alternative option for pain control that reduces the need for opioid analgesia. The purpose of this study was to compare the use of femoral nerve blocks versus standard pain control for patients with hip fractures. METHODS: This retrospective study included adult patients presenting to the emergency department with isolated hip fractures between April 2021 and September 2022. The intervention group included all patients who received a femoral nerve block during this time. An equivalent number of patients who received standard pain control during that period was randomly selected to represent the control group. The primary outcome was preoperative opioid requirement, assessed by morphine milligram equivalents (MMEs). RESULTS: During the study period, 90 patients were included in each group. Mean preoperative MME was 10.3 (95% confidence interval [CI], 7.4-13.2 MME) for the intervention group and 14.0 (95% CI, 10.2-17.8 MME) for the control group (P=0.13). Patients who received a femoral nerve block also had shorter time from emergency department triage to hospital discharge (7.2 days; 95% CI, 6.2-8.0 days) than patients who received standard care (8.6 days; 95% CI, 7.210.0 days). However, this difference was not statistically significant (P=0.09). CONCLUSION: Femoral nerve blockade is a safe and effective alternative to opioids for pain control in patients with hip fractures.

The Effect of a Nursing Hold Team on Patient Satisfaction for Admitted Patients Discharged Directly From the Emergency Department.

OBJECTIVES: Emergency departments (ED) across the United States face challenges related to patient volume, available capacity, and patient throughput. Patient satisfaction is adversely affected by crowding and lengthy boarding times. This study aimed to determine whether the implementation of a dedicated nursing hold team (NHT) would improve patient satisfaction scores for admitted patients discharged directly from the ED. METHODS: This was a retrospective, observational study with a pre-/post-test design. All admitted adult patients who returned a Press Ganey (PG) survey were included in the study. There were two twelve-month study periods before and after implementing an ED NHT. The primary outcome was the percentage of patients who gave top box scores for all questions in the Nursing Communication Domain. RESULTS: During the pre-implementation period, 108 patients (59%) gave an overall top box rating for the Nursing Communication Domain versus the post-implementation period, where 99 patients (66%) provided a top box rating (OR 1.375, p = 0.16). There was a trend toward increased satisfaction for individual categories. However, these differences were not statistically significant. CONCLUSIONS: Implementing a dedicated NHT showed an increase in the overall top box PG Nursing Communication Domain score and several of the individual domain questions. Future studies should examine other potential benefits from a dedicated NHT, such as the rate of adverse events and medication delays.

Resource utilization of adult patients referred to the emergency department from an urgent care center.

BACKGROUND: The rise of urgent care centers (UCC) continues to serve as an alternative to emergency departments (ED) for patients with a perceived lower acuity complaint. Patients that are deemed to be higher acuity are often evaluated at an UCC and then redirected to EDs. However, limited data exist on resource utilization by patients who are transferred from UCCs to EDs. The objective of this study was to compare resource utilization in the ED between patients who were transferred from UCCs and those who were initially evaluated in the ED. METHODS: This was a retrospective study of adult patients transferred from UCCs in Staten Island, NY to Staten Island University Hospital, between 1 March 2018 and 31 December 2018.  The first group (UCC Group) included those initially evaluated at an UCC and then referred to the ED. The second group (ED Group) included those who had their initial evaluation in the ED. RESULTS: 572 subjects were enrolled in the UCC Group, and 84,481 in the ED Group. The UCC Group was more likely to undergo laboratory tests, plain radiographs and computed tomography, electrocardiograms, intravenous fluids, and parenteral medications. Patients in the UCC group were also more likely to be admitted to an inpatient bed or placed into ED observation (p < 0.0001). Overall, ED length of stay was longer in the UCC Group (p < 0.001). CONCLUSIONS: Patients referred from an UCC required more ED resources and were more likely to be admitted to a hospital bed compared to those who initially self-referred to the ED.

Development and Implementation of an Alternate Care Site During the COVID-19 Pandemic.

Introduction With the rampant spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the subsequent pandemic of coronavirus disease 2019 (COVID-19), the need for medical resources has never been greater. In recent history, the deployment of surge medical facilities and their importance in improving the provision of crisis care became relevant. The primary objective of this study was to describe the development and implementation of an alternate care site (ACS) during the COVID-19 pandemic. Methods This was a retrospective, single-center study that was conducted between April 7, 2020, and May 26, 2020, of adult patients from a primary facility admitted to an ACS, labeled Staten Island University Hospital East (SIUH-E). These select patients met specific inclusion criteria for SIUH-E before transfer. Results During the operational course of SIUH-E, 813 patients were screened and 203 patients were accepted for transfer. Of the patients admitted to SIUH-E, 120 (59%) were male. The mean age was 63 years (SD = 13.91). The mean length of stay was 3.93 days (SD = 3.94). Among discharged patients, 179 (88%) were discharged to home or another long-term facility, whereas 24 (12%) patients required a transfer back to the main campus. Conclusions In this study, we describe the development and implementation of an alternate care surge facility during the COVID-19 pandemic. SIUH-E played a vital role in effectively caring for select COVID-19 patients, which allowed the primary facilities to treat a greater volume of higher acuity patients. The combined efforts of the state and hospital were able to create and sustain a safe, practical alternative care facility.

Effects of eliminating routine use of oral contrast for computed tomography of the abdomen and pelvis: A pilot study.

INTRODUCTION: Computed tomography (CT) of the abdomen and pelvis using only intravenous contrast has been shown to have a high degree of accuracy in evaluating abdominal pain. The aim of this study was to determine the effect on time to completion of study, time to radiologist read, and length of stay in the emergency department (ED) of implementing a protocol that stopped the routine use of oral contrast for CT of the abdomen and pelvis. METHODS: This was a single-center, retrospective cohort study. All patients ≥18 years of age who presented to the ED and required a CT of the abdomen and pelvis during the hours 0700-1500 were included. There were two one-month study periods, before and after implementing a protocol that specified oral contrast should only be used for CT scans of the abdomen and pelvis if body mass index <25 kg/m2 or age < 30 years, or if there was history of inflammatory bowel disease, gastrointestinal surgery, or suspected bowel malignancy. RESULTS: During the pre- and post-implementation periods, there were 93 and 83 patients, respectively, with mean times to CT completion of 158 min and 135 min, representing a reduction of 23 min (15%). The mean lengths of stay in the pre- and post-implementation periods were 365 min and 336 min, a decrease of 29 min (8%). CONCLUSION: A protocol without the routine use of oral contrast for CT of the abdomen and pelvis can result in improved time to completion and ED length of stay.

A Novel Approach to Addressing an Unintended Consequence of Direct to Room: The Delay of Initial Vital Signs.

INTRODUCTION: The concept of "direct to room" (DTR) and "immediate bedding" has been described in the literature as a mechanism to improve front-end, emergency department (ED) processing. The process allows for an expedited clinician-patient encounter. An unintended consequence of DTR was a time delay in obtaining the initial set of vital signs upon patient arrival. METHODS: This retrospective cohort study was conducted at a single, academic, tertiary-care facility with an annual census of 94,000 patient visits. Inclusion criteria were all patients who entered the ED from 11/1/15 to 5/1/16 and between the hours of 7 am to 11 pm. During the implementation period, a vital signs station was created and a personal care assistant was assigned to the waiting area with the designated job of obtaining vital signs on all patients upon arrival to the ED and prior to leaving the waiting area. Time to first vital sign documented (TTVS) was defined as the time from quick registration to first vital sign documented. RESULTS: The pre-implementation period, mean TTVS was 15.3 minutes (N= 37,900). The post-implementation period, mean TTVS was 9.8 minutes (N= 39,392). The implementation yielded a 35% decrease and an absolute reduction in the average TTVS of 5.5 minutes (p<0.0001). CONCLUSION: This study demonstrated that the coupling of registration and a vital signs station was successful at overcoming delays in obtaining the time to initial vital signs.

Extended venous thromboembolism prophylaxis after total hip replacement: a comparison of low-molecular-weight heparin with oral anticoagulant.

BACKGROUND: Oral anticoagulants and low-molecular-weight heparin are both recommended for venous thromboembolism prophylaxis after total hip replacement. To date, these regimens have not been compared by means of clinical end points in the extended prophylaxis setting. METHODS: We randomly assigned 1279 patients 3 days after total hip replacement surgery to fixed-dose subcutaneous low-molecular-weight heparin (reviparin sodium, 4200 anti-Xa IU) or adjusted-dose oral anticoagulant (international normalized ratio, 2-3; acenocoumarol) for a 6-week period. The primary end point was the failure rate, defined as the combined clinical events of a confirmed symptomatic thromboembolic event, a major hemorrhage, or death. All patients were followed up throughout the study interval. The primary objective was to compare the observed cumulative failure rate in the low-molecular-weight heparin vs oral anticoagulant group. RESULTS: In the intent-to-treat population, objectively documented symptomatic thromboembolic events occurred in 15 (2.3%) of 643 patients vs 21 (3.3%) of 636 patients receiving low-molecular-weight heparin or oral anticoagulants, respectively (P =.30; 95% confidence interval for the difference, -0.8% to 2.8%). Major bleeding occurred in 9 (1.4%) of 643 patients vs 35 (5.5%) of 636 patients receiving low-molecular-weight heparin or oral anticoagulants, respectively (P =.001). The failure rate was 24 (3.7%) of 643 patients compared with 53 (8.3%) of 636 patients who received low-molecular-weight heparin or oral anticoagulants (P =.001). CONCLUSIONS: A significantly higher benefit-risk ratio was observed for patients undergoing elective hip replacement who received extended out-of-hospital prophylaxis with low-molecular-weight heparin vs acenocoumarol. Low-molecular-weight heparin prophylaxis was at least as effective as oral anticoagulants, but with a marked improvement in safety.

Controlling molecular crystal polymorphism with self-assembled monolayer templates.

The control of crystal polymorphism is a long-standing issue in solid-state chemistry, which has many practical implications for a variety of commercial applications. At least four different crystalline forms of 1,3-bis(m-nitrophenyl) urea (MNPU), a classic molecular crystal system, are known to crystallize from solution in various concomitant combinations. Herein we demonstrate that the introduction of gold-thiol self-assembled monolayers (SAMs) of substituted 4'-X-mercaptobiphenyls (X = H, I, and Br) into the crystallization solution can serve as an effective means to selectively template the nucleation and growth of alpha-, beta-, and gamma-MNPU phases, respectively. Polymorph control in the presence of SAM surfaces persists under a variety of solution conditions and consistently results in crystalline materials with high phase purity. The observed selectivity is rationalized on the basis of long-range two-dimensional geometric lattice matching and local complementary chemical interactions at the SAM/crystal interfaces.