Evaluation of Process Improvement Interventions on Handoff Times between the Emergency Department and Observation Unit.

BACKGROUND: Mitigating hospital crowding requires judicious use of inpatient resources, making Emergency Department Observation Units (EDOUs) an increasingly vital destination for patients that are not suitable for discharge. Maximizing the utility of the EDOU hinges on efficient patient transfers and safe provider communication, which may be accomplished with asynchronous handoff and an emphasis on pull-through operations. OBJECTIVE: The purpose of this study was to assess the impact of an electronic, asynchronous handoff replacing verbal handoff on transfer times from the Emergency Department (ED) to the EDOU. METHODS: A retrospective observational study was performed with patients transferred to the EDOU throughout several process improvement measures focused on asynchronous handoff. Multivariable linear regression analysis was used to determine the effect that these process improvements had on the time from EDOU bed assignment to patient transfer. RESULTS: There were 14,996 EDOU stays during the 20-month period included in the analysis. Time from EDOU bed assignment to patient transfer decreased significantly with all three interventions studied. An auto-page to the clinicians notifying them of a ready bed reduced the mean time to transfer by 10.1 min (p < 0.0001), asynchronous nursing handoff reduced it by 3.57 min (p = 0.0299), and asynchronous clinician handoff reduced it by 14.67 min (p < 0.0001). CONCLUSION: Introducing automatic pages regarding bed status and converting the handoff process from a verbal model to an asynchronous, electronic handoff were effective ways to reduce the time from bed assignment to transfer out of the ED for patients being sent to the EDOU.

Does physician leadership affect hospital quality, operational efficiency, and financial performance?

BACKGROUND: With payers and policymakers' focus on improving the value (health outcomes achieved per health care dollar spent) of health care delivery, physicians are increasingly taking on senior leadership/management positions in health care organizations (Carsen & Xia, 2006). Little research has been done to understand the impact of physician leadership on the delivery of care. PURPOSE: The aim of this study was to examine whether hospital systems led by physicians were associated with better U.S. News and World Report (USNWR) quality ratings, financial performance, and operating efficiency as compared with those led by nonphysician managers. METHODOLOGY: Cross-sectional analysis of nationally representative data from Medicare Cost Reports and the USNWR on the 115 largest U.S. hospitals was performed. Bivariate analysis of physician-led and non-physician-led hospital networks included three categories: USNWR quality ratings, hospital volume, and financial performance. Multivariate analysis of hospital leadership, percent operating margin, inpatient days per hospital bed, and average quality rating was subsequently performed. RESULTS: Hospitals in physician-led hospital systems had higher quality ratings across all specialties and more inpatient days per hospital bed than did non-physician-led hospitals; however, there were no differences in the total revenue or profit margins between the groups. Physician leadership was independently associated with higher average quality ratings and inpatient days per bed. CONCLUSIONS: Large hospital systems led by physicians in 2015 received higher USNWR ratings and bed usage rates than did hospitals led by nonphysicians, with no differences in financial performance. This study suggests that physician leaders may possess skills, qualities, or management approaches that positively affect hospital quality and the value of care delivered. PRACTICE IMPLICATIONS: Hospital quality and efficiency ratings vary significantly and can impact consumer decisions. Hospital systems may benefit from the presence of physician leadership to improve the quality and efficiency of care delivered to patients. In addition, medical education should help prepare physicians to take on leadership roles in hospitals and health systems.

Discharge Destination After Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes, Placement Risk Factors, and Recent Trends.

BACKGROUND: This study aimed to compare risk of postdischarge adverse events in elective total joint arthroplasty (TJA) patients by discharge destination, identify risk factors for inpatient discharge placement and postdischarge adverse events, and stratify TJA patients based on these risk factors to identify the most appropriate discharge destination. METHODS: Patients who underwent elective primary total hip or knee arthroplasty from 2011 to 2013 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses were assessed using perioperative variables. RESULTS: A total of 106,360 TJA patients were analyzed. The most common discharge destinations included home (70%), skilled nursing facility (SNF) (19%), and inpatient rehabilitation facility (IRF; 11%). Bivariate analysis revealed that rates of postdischarge adverse events were higher in SNF and IRF patients (all P ≤ .001). In multivariate analysis controlling for patient characteristics, comorbidities, and incidence of complication predischarge, SNF and IRF patients were more likely to have postdischarge severe adverse events (SNF: odds ratio [OR]: 1.46, P ≤ .001; IRF: OR: 1.59, P ≤ .001) and unplanned readmission (SNF: OR: 1.42, P ≤ .001; IRF: OR: 1.38, P ≤ .001). After stratifying patients by strongest independent risk factors (OR: ≥1.15, P ≤ .05) for adverse outcomes after discharge, we found that home discharge is the optimal strategy for minimizing rate of severe 30-day adverse events after discharge (P ≤ .05 for 5 out of 6 risk levels) and unplanned 30-day readmissions (P ≤ .05 for 6 out of 7 risk levels). Multivariate analysis revealed incidence of severe adverse events predischarge, female gender, functional status, body mass index >40, smoking, diabetes, pulmonary disease, hypertension, and American Society of Anesthesiologists class 3/4 as independent predictors of nonhome discharge (all P ≤ .001). CONCLUSION: SNF or IRF discharge increases the risk of postdischarge adverse events compared to home. Modifiable risk factors for nonhome discharge and postdischarge adverse events should be addressed preoperatively to improve patient outcomes across discharge settings.

An Analysis of Ambulance Transport and Out-of-Network Emergency Department Utilization in an Accountable Care Organization.

For hospital-affiliated accountable care organizations (ACOs), emergency care represents a unique challenge for coordination of care and a major source of ACO leakage. The authors analyzed emergency department (ED) visits among ACO members to assess the potential impact of ambulance transport on the use of in-network versus out-of-network EDs. To better understand factors influencing the use of in-network versus out-of-network EDs, 2018 claims data from members of a regional subset of a large ACO in the greater Boston area were analyzed. Within this population, multivariable logistic regression was used to assess the relationship between ambulance transport as well as demographic factors, insurance type, and hospital distance on the use of in-network versus out-of-network EDs. Arrival to an ED via ambulance was found to be significantly associated with reduced odds of presenting to an in-network ED compared to arriving by private transportation (odds ratio 0.70, 95% confidence interval: 0.58-0.85). Age older than 65 years, commercial insurance (relative to Medicare), proximity to an in-network ED, and distance from an out-of-network ED also were significantly associated with use of in-network EDs relative to out-of-network EDs. Given the central role of the ED as a primary source of hospital admissions in the United States, emergency care represents a key potential target for interventions aimed at reducing patient leakage. Future efforts should aim to identify and evaluate new ways that emergency medical services can be leveraged to promote effective care coordination.