Hospital-based pandemic influenza preparedness and response: strategies to increase surge capacity.

UNLABELLED: In the spring of 2009, the first patients infected with 2009 H1N1 virus were arriving for care in hospitals in the United States. Anticipating a second wave of infection, our hospital leaders initiated multidisciplinary planning activities to prepare to increase capacity by expansion of emergency department (ED) and inpatient functional space and redeployment of medical personnel. EXPERIENCE: During the fall pandemic surge, this urban, tertiary-care children's hospital experienced a 48% increase in ED visits and a 12% increase in daily peak inpatient census. However, several strategies were effective in mitigating the pandemic's impact including using a portion of the hospital's lobby for ED waiting, using a subspecialty clinic and a 24-hour short stay unit to care for ED patients, and using physicians not board certified in pediatric emergency medicine and inpatient-unit medical nurses to care for ED patients. The average time patients waited to be seen by an ED physician and the proportion of children leaving the ED without being seen by a physician was less than for the period when seasonal influenza peaked in the winter of 2008-2009. Furthermore, the ED did not go on divert status, no elective medical or surgical admissions required cancellation, and there were no increases in serious patient safety events. SUMMARY: Our health center successfully met the challenges posed by the 2009 H1N1 outbreak. The intent in sharing the details of our planning and experience is to allow others to determine which elements of this planning might be adapted for managing a surge of patients in their setting.

Reducing electronic health record-related burnout in providers through a personalized efficiency improvement program.

OBJECTIVE: To give providers a better understanding of how to use the electronic health record (EHR), improve efficiency, and reduce burnout. MATERIALS AND METHODS: All ambulatory providers were offered at least 1 one-on-one session with an "optimizer" focusing on filling gaps in EHR knowledge and lack of customization. Success was measured using pre- and post-surveys that consisted of validated tools and homegrown questions. Only participants who returned both surveys were included in our calculations. RESULTS: Out of 1155 eligible providers, 1010 participated in optimization sessions. Pre-survey return rate was 90% (1034/1155) and post-survey was 54% (541/1010). 451 participants completed both surveys. After completing their optimization sessions, respondents reported a 26% improvement in mean knowledge of EHR functionality (P < .01), a 19% increase in the mean efficiency in the EHR (P < .01), and a 17% decrease in mean after-hours EHR usage (P < .01). Of the 401 providers asked to rate their burnout, 32% reported feelings of burnout in the pre-survey compared to 23% in the post-survey (P < .01). Providers were also likely to recommend colleagues participate in the program, with a Net Promoter Score of 41. DISCUSSION: It is possible to improve provider efficiency and feelings of burnout with a personalized optimization program. We ascribe these improvements to the one-on-one nature of our program which provides both training as well as addressing the feeling of isolation many providers feel after implementation. CONCLUSION: It is possible to reduce burnout in ambulatory providers with personalized retraining designed to improve efficiency and knowledge of the EHR.

Return visits to a pediatric emergency department.

OBJECTIVES: To determine the incidence of return visits (RVs), types of RVs, and factors associated with RVs to a pediatric emergency department (ED). METHODS: : Retrospective cohort study of patients seen in an urban, tertiary care pediatric ED. MAIN OUTCOME: RV within 48 hours, identified from a computerized log. RESULTS: The total RV rate was 3.5% (95% confidence interval, 3.3-3.6), similar to rates (2.4% to 3.4%) reported in general EDs. Most (78.5%) RVs were unscheduled, 17% were scheduled, and 4% were called back to the ED. Infectious disease (45%), respiratory (16%), and trauma (16%) accounted for most RV diagnoses. When compared with the overall ED population, RV patients were more likely to be younger than 2 years [relative risk, 1.3 (1.2-1.4)], to be admitted to the hospital [relative risk, 1.3 (1.2-1.5)], and to be triaged as acute [relative risk, 1.1 (1.0-1.2)]. Patients called back to the ED were younger, more likely to be triaged as acute, and more likely to be admitted than other RV patients. Significant diagnoses were made at RV in 7 (0.4%; 95% confidence interval, 0.1-0.7) patients, half of whom were called back to the ED or had a scheduled RV. CONCLUSION: Similarities between our pediatric ED RV rate and other published research implies that benchmarking and quality improvement tools for RV can be used and compared in both pediatric and general EDs. Focusing on systems to call patients back to the ED when necessary may be an efficient way to reduce medical error and adverse patient outcomes.