Daytime Versus Nighttime Extubations: A Comparison of Reintubation, Length of Stay, and Mortality.

PURPOSE: Despite studies regarding outcomes of day versus night medical care, consequences of nighttime extubations are unknown. It may be favorable to extubate patients off-hours, as soon as weaning parameters are met, since this could decrease complications and shorten length of stay (LOS). Conversely, nighttime extubation could be deleterious, as staffing varies during this time. We hypothesized that patients have similar reintubation rates, irrespective of extubation time. METHODS: A retrospective cohort study performed at 2 hospitals within a tertiary academic medical center included all adult intensive care unit (ICU) patients extubated between July 01, 2009 and May 31, 2011. Those extubated due to withdrawal of support were excluded. The nighttime group included patients extubated between 7:00 pm and 6:59 am and the daytime group included patients extubated between 7:00 am and 6:59 pm. RESULTS: Of 2240 extubated patients, 1555 were extubated during the day and 685 were extubated at night. Of these, 119 (7.7%) and 26 (3.8%), respectively, were reintubated in 24 hours with likelihood of reintubation significantly lower for nighttime than daytime after multivariable adjustment (odds ratio [OR] = 0.5, 95% confidence interval [CI] 0.3-0.9, P = .01), with a similar trend for reintubation within 72 hours (OR = 0.7, 95% CI = 0.5-1.0, P = .07). There was a trend toward decreased mortality for patients extubated at night (OR = 0.6, 95% CI = 0.3-1.0, P = .06). There was also a significantly lower LOS for patients extubated at night (P = .002). In a confirmatory frequency-matched analysis, there was no significant difference in reintubation proportion or mortality, but LOS was significantly less in those extubated at night. CONCLUSIONS: Intensive care unit extubations at night did not have higher likelihood of reintubation, LOS, or mortality compared to those during the day. Since patients should be extubated as soon as they meet parameters in order to potentially decrease complications of mechanical ventilation, these data provide no support for delaying extubation until daytime.

Assessing Patient Experience and Orientation in the Emergency Department with Virtual Windows.

Patients have benefitted from increasingly sophisticated diagnostic and therapeutic innovations over the years. However, the design of the physical hospital environment has garnered less attention. This may negatively impact a patient's experience and health. In areas of the hospital, such as the emergency department (ED), patients may spend hours, or even days, in a windowless environment. Studies have highlighted the importance of natural light and imagery, as they are essential in providing important stimuli to regulate circadian rhythm and orientation, and to mitigate the onset of certain medical conditions. In hospital locations where standard windows may be infeasible, the use of a virtual window may simulate the benefits of an actual window. In this pilot study, we assessed patient experience and orientation with virtual windows in the ED. We demonstrated that virtual windows are an acceptable technology that may improve patient experience and orientation.

Home hospital as a disposition for older adults from the emergency department: Benefits and opportunities.

The $1 trillion industry of acute hospital care in the United States is shifting from inside the walls of the hospital to patient homes. To tackle the limitations of current hospital care in the United States, on November 25, 2020, the Center for Medicare & Medicaid Services announced that the acute hospital care at home waiver would reimburse for "home hospital" services. A "home hospital" is the home-based provision of acute services usually associated with the traditional inpatient hospital setting. Prior work suggests that home hospital care can reduce costs, maintain quality and safety, and improve patient experiences for select acutely ill adults who require hospital-level care. However, most emergency physicians are unfamiliar with the evidence of benefits demonstrated by home hospital services, especially for older adults. Therefore, the lead author solicited narrative inputs on this topic from selected experts in emergency medicine and home hospital services with clinical experience, publications, and funding on home hospital care. Then we sought to identify information most relevant to the practice of emergency medicine. We outline the proven and potential benefits of home hospital services specific to older adults compared to traditional acute care hospitalization with a focus on the emergency department.

Mobile app helps trainees manage emergencies at the bedside.

BACKGROUND: Although emergency departments (ED) have standardized guidelines for low-frequency, high-acuity diagnoses, they are not immediately accessible at the bedside, and this can cause anxiety in trainees and delay patient care. This problem is exacerbated during events like COVID-19 that require the rapid creation, iteration, and dissemination of new guidelines. METHODS: Physician innovators used design thinking principles to develop EM Protocols (EMP), a mobile application that clinicians can use to immediately view guidelines, contact consultants (e.g., cath lab activation), and access code-running tools. The project became an institutional high priority, because it helps EM trainees and off-service rotators manage low-frequency, high-acuity emergencies at the point of care, and its COVID-19 guidelines can be rapidly updated and disseminated in real time. RESULTS: This intervention was deployed across two academic medical centers during the COVID-19 surge. Nearly 300 ED clinicians have downloaded EMP, and they have interacted with the app over 5,400 times. It continues to be used regularly, over 12 months after the initial surge. Since the app was received positively, there are efforts to build in additional adult and pediatric guidelines. DISCUSSION: Digital health tools like EMP can serve as invaluable adjuncts for managing acute, life-threatening emergencies at the point of care. They can benefit trainees during normal day-to-day operations as well as scenarios that cause large-scale operational disruptions, such as natural disasters, mass casualty events, and future pandemics.

Digital triage: Novel strategies for population health management in response to the COVID-19 pandemic.

The COVID-19 pandemic has created unique challenges for the U.S. healthcare system due to the staggering mismatch between healthcare system capacity and patient demand. The healthcare industry has been a relatively slow adopter of digital innovation due to the conventional belief that humans need to be at the center of healthcare delivery tasks. However, in the setting of the COVID-19 pandemic, artificial intelligence (AI) may be used to carry out specific tasks such as pre-hospital triage and enable clinicians to deliver care at scale. Recognizing that the majority of COVID-19 cases are mild and do not require hospitalization, Partners HealthCare (now Mass General Brigham) implemented a digitally-automated pre-hospital triage solution to direct patients to the appropriate care setting before they showed up at the emergency department and clinics, which would otherwise consume resources, expose other patients and staff to potential viral transmission, and further exacerbate supply-and-demand mismatching. Although the use of AI has been well-established in other industries to optimize supply and demand matching, the introduction of AI to perform tasks remotely that were traditionally performed in-person by clinical staff represents a significant milestone in healthcare operations strategy.