Objective measures of workload in healthcare: a narrative review.

PURPOSE: Workload is a critical concept in the evaluation of performance and quality in healthcare systems, but its definition relies on the perspective (e.g. individual clinician-level vs unit-level workload) and type of available metrics (e.g. objective vs subjective measures). The purpose of this paper is to provide an overview of objective measures of workload associated with direct care delivery in tertiary healthcare settings, with a focus on measures that can be obtained from electronic records to inform operationalization of workload measurement. DESIGN/METHODOLOGY/APPROACH: Relevant papers published between January 2008 and July 2018 were identified through a search in Pubmed and Compendex databases using the Sample, Phenomenon of Interest, Design, Evaluation, Research Type framework. Identified measures were classified into four levels of workload: task, patient, clinician and unit. FINDINGS: Of 30 papers reviewed, 9 used task-level metrics, 14 used patient-level metrics, 7 used clinician-level metrics and 20 used unit-level metrics. Key objective measures of workload include: patient turnover (n=9), volume of patients (n=6), acuity (n=6), nurse-to-patient ratios (n=5) and direct care time (n=5). Several methods for operationalization of these metrics into measurement tools were identified. ORIGINALITY/VALUE: This review highlights the key objective workload measures available in electronic records that can be utilized to develop an operational approach for quantifying workload. Insights gained from this review can inform the design of processes to track workload and mitigate the effects of increased workload on patient outcomes and clinician performance.

Skin dimpling after a closed proximal humerus fracture.

BACKGROUND: Skin dimpling, also known as skin puckering, is a rare occurrence after closed proximal humerus fractures. This finding is suggestive of incarceration of the skin at the fracture site and may lead to necrosis and conversion to an open fracture. OBJECTIVES: Our goal is to describe our experience with skin dimpling after a proximal humerus fracture to increase awareness and recognition of this clinical presentation in the Emergency Department (ED). CASE REPORT: We report a case of a 46-year-old woman who presented to the ED with left shoulder pain and swelling after a fall. She was found to have skin dimpling over the anterior aspect of the shoulder on further examination and was diagnosed with a proximal humerus fracture after imaging. CONCLUSION: Skin dimpling is an uncommon sign associated with proximal humerus fractures that can help in diagnosis and determining course of treatment. Devastating soft tissue injury can occur if the fracture is not immediately reduced. Therefore, it is imperative that physicians be able to promptly identify the clinical presentation to prevent unwanted sequelae.

Notice to comply: A systematic review of clinician compliance with guidelines surrounding acute hospital-based infection management.

PURPOSE: To identify and characterize studies evaluating clinician compliance with infection-related guidelines, and to explore trends in guideline design and implementation strategies. DATA SOURCES: PubMed database, April 2017. Followed the PRISMA Statement for systematic reviews. STUDY SELECTION: Scope was limited to studies reporting compliance with guidelines pertaining to the prevention, detection, and/or treatment of acute hospital-based infections. Initial search (1,499 titles) was reduced to 49 selected articles. DATA EXTRACTION: Extracted publication and guideline characteristics, outcome measures reported, and any results related to clinician compliance. Primary summary measures were frequencies and distributions of characteristics. Interventions that led to improved compliance results were analyzed to identify trends in guideline design and implementation. RESULTS OF DATA SYNTHESIS: Of the 49 selected studies, 18 (37%), 13 (27%), and 10 (20%) focused on sepsis, pneumonia, and general infection, respectively. Six (12%), 17 (35%), and 26 (53%) studies assessed local, national, and international guidelines, respectively. Twenty studies (41%) reported 1-instance compliance results, 28 studies (57%) reported 2-instance compliance results (either before-and-after studies or control group studies), and 1 study (2%) described compliance qualitatively. Average absolute change in compliance for minimal, decision support, and multimodal interventions was 10%, 14%, and 25%, respectively. Twelve studies (24%) reported no patient outcome alongside compliance. CONCLUSIONS: Multimodal interventions and quality improvement initiatives seem to produce the greatest improvement in compliance, but trends in other factors were inconsistent. Additional research is required to investigate these relationships and understand the implications behind various approaches to guideline design, communication, and implementation, in addition to effectiveness of protocol impact on relevant patient outcomes.

TelEmergency: a novel system for delivering emergency care to rural hospitals.

Providing rural emergency medical care is often difficult because of limited resources and a scarcity of medical providers, including physicians trained in emergency medicine. Telemedicine offers promise for improving the quality of care in rural areas, but previous models were not well designed to provide affordable care to unstable or potentially unstable patients. The TelEmergency program was developed to overcome these limitations by providing quality, affordable medical care to patients in rural emergency departments (EDs) using specially trained nurse practitioners linked in real time by telemedicine with their collaborating physicians at the University of Mississippi Medical Center Adult Emergency Department. Since its inception in October 2003, the TelEmergency program has evaluated and treated more than 40,000 patients in 11 rural EDs throughout Mississippi, with a high degree of satisfaction from patients and hospital administrators. This article details the development and implementation of this system and describes the patient population that has been evaluated.