Measuring Sensitivity and Precision of Real-Time Location Systems (RTLS): Definition, Protocol and Demonstration for Clinical Relevance.

The ability of a Real Time Location System (RTLS) to provide correct information in a clinical environment is an important consideration in evaluating the effectiveness of the technology. While past efforts describe how well the technology performed in a lab environment, the performance of such technology has not been specifically defined or evaluated in a practice setting involving workflow and movement. Clinical environments pose complexity owing to various layouts and various movements. Further, RTL systems are not equipped to provide true negative information (where an entity is not located). Hence, this study defined sensitivity and precision in this context, and developed a simulation protocol to serve as a systematic testing framework using actors in a clinical environment. The protocol was used to measure the sensitivity and precision of an RTL system in the emergency department space of a quaternary care medical center. The overall sensitivity and precision were determined to be 84 and 93% respectively. These varied for patient rooms, staff area, hallway and other rooms.

Characterization of emergency department abandonment using a real-time location system.

BACKGROUND: Patients who present to emergency departments (EDs) for evaluation but are noted to have left without being seen (LWBS) are potentially at great risk. Governmental agencies, such as the Centers for Medicare and Medicaid, as well as hospitals and health organizations, are examining the factors which drive LWBS, including accurately quantifying patient tolerance to wait times and targeting interventions to improve patient tolerance to waiting. OBJECTIVE: Compare traditional methods of estimating time to LWBS with an objective method using a real-time location tracking system (RTLS); examine temporal factors associated with greater LWBS rates. METHODS: This is a retrospective cohort study of all ED visits to a large, suburban, quaternary care hospital in one calendar year. LWBS was calculated as patient registration to nurse recognition and documentation of patient abandonment (traditional method) vs registration to last onsite RTLS timestamp (study method). Descriptives of patterns of patient abandonment rates and patient demographic data were also included. RESULTS: Our study shows that traditional methods of measuring LWBS times significantly overestimate actual patient tolerance to waiting times (median 70, mean 92 min). Patients triaged to resource intensive categories (Emergency Severity Index (ESI) 2, 3) wait longer than patients triaged to less resource intensive categories (ESI 4, 5). CONCLUSION: Compared to traditional methods, RTLS is an efficient and accurate way to measure LWBS rates and helps set the stage for assessing the efficacy of interventions to reduce LWBS and reduce the gap between those seeking evaluation at emergency departments and those ultimately receiving it.

Impact of scribes on throughput metrics and billing during an electronic medical record transition.

OBJECTIVE: Evaluate an established scribe program on throughput and revenue capture in an Emergency Department (ED) undergoing an EMR transition. METHODS: A prospective cohort design comparing patients managed with and without scribes in an academic ED. Throughput metrics (medians, min) and relative value units (RVUs, means) were collected. Data was evaluated in its entirety (three months), as well as in two subsets: go live (immediate two weeks) and adoption (two weeks post implementation to end). RESULTS: All patients: There was no significant difference in throughput or RVUs during the three month period. During go-live, scribes showed improvement in total RVUs per patient (4.63 vs 4.40, p = 0.048). During adoption, scribed patients had decreased length of stay (LOS, 221 vs 231, p = 0.023). Adults: Door to provider (28 vs 37, p = 0.014) and total RVUs (5.20 vs 4.92, p = 0.042) were improved with scribes in the go-live period. Scribes improved go-live morning and overnight shifts, while lengthening provider to disposition during afternoon shifts. No significant differences were seen in the adoption period, except for increased provider to disposition time overnight with scribes (154 vs 146, p = 0.030). Pediatrics: When all pediatric patients were compared, scribe patients had a decreased professional RVU charge (2.78 vs 2.90, p = 0.037). During go live and adoption, no significant differences were found in any other parameter or subgrouping. CONCLUSIONS: A scribe's ability to mitigate operational inefficiencies introduced by an EMR transition seems limited in an academic hospital. Previous research highlighting the impact of scribes on revenue was not replicated during this study.

Unnecessary wait hours: a novel ED system-level metric.

BACKGROUND: Emergency department (ED) operations leaders are under increasing pressure to make care delivery more efficient. Publicly reported ED efficiency metrics are traditionally patient centred and do not show situational or facility-based improvement opportunities. We propose the consideration of a novel metric, the 'Number of Unnecessary Waits (NUW)' and the corresponding 'Unnecessary Wait Hours (UWH)', to measure space efficiency, and we describe how we used NUW to evaluate operational changes in our ED. METHODS: UWH summarises the relationship between the number of available rooms and the number of patients waiting by returning a value equal to the number of unnecessary patient waits. We used this metric to evaluate reassigning a clinical technician assistant (CTA) to the new role of flow CTA. RESULTS: We retrospectively analysed 3.5 months of data from before and after creation of the flow CTA. NUW metric analysis suggested that the flow CTA decreased the amount of unnecessary wait hours, while higher patient volumes had the opposite effect. CONCLUSIONS: Situational system-level metrics may provide a new dimension to evaluating ED operational efficiencies. Studies focussed on system-level metrics to evaluate an ED practice are needed to understand the role these metrics play in evaluation of a department's operations.

Mobile Point-of-Care Medical Photography: Legal Considerations for Health Care Providers.

Medical photographs have been used for decades to document clinical findings. The ease with which medical photographs can be captured and integrated into the electronic health record (EHR) has increased as digital cameras obviated the need for the film development process. Today, cameras integrated into smartphones allow for high-resolution images to be instantly uploaded and integrated into the EHR. With major EHR vendors offering mobile smartphone applications for the conduct of point-of-care medical photography, health care providers and institutions need to be aware of legal questions that arise in the conduct of medical photography. Namely, (1) what are the requirements for consent when taking medical photographs, and how may photographs be used after consent is obtained, (2) are medical photographs admissible as evidence in court, and (3) how should a provider respond to a request by a patient or parent requesting that a photograph be deleted from the medical record? Herein, we review relevant laws and legal cases in the context of accepted standards of medical practice pertaining to point-of-care medical photography. This review is intended to aid health care providers and institutions seeking to develop or revise policies regarding using a mobile application at their clinical practice.

Physician, Interrupted: Workflow Interruptions and Patient Care in the Emergency Department.

BACKGROUND: It is unclear how workflow interruptions impact emergency physicians at the point of care. OBJECTIVES: Our study aimed to evaluate interruption characteristics experienced by academic emergency physicians. METHODS: This prospective, observational study collected interruptions during attending physician shifts. An interruption is defined as any break in performance of a human activity that briefly requires attention. One observer captured interruptions using a validated tablet PC-based tool that time stamped and categorized the data. Data collected included: 1) type, 2) priority of interruption to original task, and 3) physical location of the interruption. A Kruskal-Wallis H test compared interruption priority and duration. A chi-squared analysis examined the priority of interruptions in and outside of the patient rooms. RESULTS: A total of 2355 interruptions were identified across 210 clinical hours and 28 shifts (means = 84.1 interruptions per shift, standard deviation = 14.5; means = 11.21 interruptions per hour, standard deviation = 4.45). Physicians experienced face-to-face physician interruptions most frequently (26.0%), followed by face-to-face nurse communication (21.7%), and environment (20.8%). There was a statistically significant difference in interruption duration based on the interruption priority, χ2(2) = 643.98, p < 0.001, where durations increased as priority increased. Whereas medium/normal interruptions accounted for 53.6% of the total interruptions, 53% of the interruptions that occurred in the patient room (n = 162/308) were considered low priority (χ2 [2, n = 2355] = 78.43, p < 0.001). CONCLUSIONS: Our study examined interruptions over entire provider shifts and identified patient rooms as high risk for low-priority interruptions. Targeting provider-centered interventions to patient rooms may aid in mitigating the impacts of interruptions on patient safety and enhancing clinical care.

Pilot Study of Kano "Attractive Quality" Techniques to Identify Change in Emergency Department Patient Experience.

STUDY OBJECTIVE: We describe the use of the Kano Attractive Quality analytic tool to improve an identified patient experience gap in perceived compassion by emergency department (ED) providers. METHODS: In phase 1, point-of-service surveying assessed baseline patient perception of ED provider compassion. Phase 2 deployed Kano surveys to predict the effect of 4 proposed interventions on patient perception. Finally, phase 3 compared patients receiving standard care versus the Kano-identified intervention to assess the actual effect on patient experience. RESULTS: In phase 1, 193 of 200 surveys (97%) were completed, showing a baseline median score of 4 out of 5 (interquartile range [IQR] 3 to 5), with top box percentage of 33% for patients' perception of receiving compassionate care. In phase 2, 158 of 180 surveys (88%) using Kano-formatted questions were completed, and the data predicted that increasing shared decisionmaking would cause the greatest improvement in the patient experience. Finally, in phase 3, 45 of 49 surveys (92%) were returned and demonstrated a significant improvement in perceived concern and sensitivity, 5 (IQR 5 to 5) versus 4 (IQR 3 to 5) with a difference of 1 (95% CI 0.1-1.9) and a top box rating of 79% versus 35% with a difference of 44% (95% CI 12-66) by patients who received dedicated shared decisionmaking interventions versus those receiving standard of care. CONCLUSION: Kano analysis is likely predictive of change in patient experience. Kano methods may prove as useful in changing management of the health care industry as it has been in other industries.

Intelligent Emergency Department: Validation of Sociometers to Study Workload.

Sociometers are wearable sensors that continuously measure body movements, interactions, and speech. The purpose of this study is to test sociometers in a smart environment in a live clinical setting, to assess their reliability in capturing and quantifying data. The long-term goal of this work is to create an intelligent emergency department that captures real-time human interactions using sociometers to sense current system dynamics, predict future state, and continuously learn to enable the highest levels of emergency care delivery. Ten actors wore the devices during five simulated scenarios in the emergency care wards at a large non-profit medical institution. For each scenario, actors recited prewritten or structured dialogue while independent variables, e.g., distance, angle, obstructions, speech behavior, were independently controlled. Data streams from the sociometers were compared to gold standard video and audio data captured by two ward and hallway cameras. Sociometers distinguished body movement differences in mean angular velocity between individuals sitting, standing, walking intermittently, and walking continuously. Face-to-face (F2F) interactions were not detected when individuals were offset by 30°, 60°, and 180° angles. Under ideal F2F conditions, interactions were detected 50 % of the time (4/8 actor pairs). Proximity between individuals was detected for 13/15 actor pairs. Devices underestimated the mean duration of speech by 30-44 s, but were effective at distinguishing the dominant speaker. The results inform engineers to refine sociometers and provide health system researchers a tool for quantifying the dynamics and behaviors in complex and unpredictable healthcare environments such as emergency care.

Extended Patient Alone Time in Emergency Department Leads to Increased Risk of 30-Day Hospitalization.

OBJECTIVES: This study was conducted to describe patients at risk for prolonged time alone in the emergency department (ED) and to determine the relationship between clinical outcomes, specifically 30-day hospitalization, and patient alone time (PAT) in the ED. METHODS: An observational cohort design was used to evaluate PAT and patient characteristics in the ED. The study was conducted in a tertiary academic ED that has both adult and pediatric ED facilities and of patients placed in an acute care room for treatment between May 1 and July 31, 2016, excluding behavioral health patients. Simple linear regression and t tests were used to evaluate the relationship between patient characteristics and PAT. Logistic regression was used to evaluate the relationship between 30-day hospitalization and PAT. RESULTS: Pediatric patients had the shortest total PAT compared with all older age groups (86.4 minutes versus 131 minutes, P < 0.001). Relationships were seen between PAT and patient characteristics, including age, geographic region, and the severity and complexity of the health condition. Controlling for Charlson comorbidity index and other potentially confounding variables, a logistic regression model showed that patients are more likely to be hospitalized within 30 days after their ED visit, with an odds ratio (95% confidence interval) of 1.056 (1.017-1.097) for each additional hour of PAT. CONCLUSIONS: Patient alone time is not equal among all patient groups. Study results indicate that PAT is significantly associated with 30-day hospitalization. This conclusion indicates that PAT may affect patient outcomes and warrants further investigation.

Experiences of Health Care Providers Using a Mobile Medical Photography Application.

OBJECTIVE: To understand the ways in which providers use a mobile photography application integrated with the electronic health record (EHR) to facilitate clinical care, and the process outcomes that result from the application's use. METHODS: An e-mail survey was sent on November 13, 2017, to 1,463 health care providers at Mayo Clinic who had used an internally developed, EHR-integrated medical photography application. RESULTS: The survey was completed by 712 (49%) providers. Providers reported using the application on approximately 1 in 7 days spent in clinical practice. Median provider satisfaction with the use of the application (0-100 scale; higher numbers indicate favorable response) was 94 (interquartile range [IQR]: 74-100). Although the use for store-and-forward telemedicine was reported (22% often or frequently used the application to send photographs to a specialist for advice), the most common use was for clinical documentation (65% often or frequently used the application to supplement text-based notes with photographs, and 71% often or frequently used the application to take photographs for reference by a colleague who may see the patient in the future). Of the health care providers, 36% indicated that the application's use often or frequently expedited treatment. DISCUSSION: Health care providers reported using a mobile point-of-care medical photography application regularly in clinical practice and were generally satisfied with the application. CONCLUSION: Point-of-care medical photography using a secure mobile, EHR-integrated application has potential to become a new standard of care for clinical documentation and may facilitate continuity across the continuum of care with multiple providers who see a patient.

Attitudes and Behavior of Health Care Workers Before, During, and After Implementation of Real-Time Location System Technology.

OBJECTIVE: To assess how staff attitudes before, during, and after implementation of a real-time location system (RTLS) that uses radio-frequency identification tags on staff and patient identification badges and on equipment affected staff's intention to use and actual use of an RTLS. PARTICIPANTS AND METHODS: A series of 3 online surveys were sent to staff at an emergency department with plans to implement an RTLS between June 1, 2015, and November 29, 2016. Each survey corresponded with a different phase of implementation: preimplementation, midimplementation, and postimplementation. Multiple logistic regression with backward elimination was used to assess the relationship between demographic variables, attitudes about RTLSs, and intention to use or actual use of an RTLS. RESULTS: Demographic variables were not associated with intention to use or actual use of the RTLS. Before implementation, poor perceptions about the technology's usefulness and lack of trust in how employers would use tracking data were associated with weaker intentions to use the RTLS. During and after implementation, attitudes about the technology's use, not issues related to autonomy and privacy, were associated with less use of the technology. CONCLUSION: Real-time location systems have the potential to assess patterns of health care delivery that could be modified to reduce costs and improve the quality of care. Successful implementation, however, may hinge on how staff weighs attitudes and concerns about their autonomy and personal privacy with organizational goals. With the large investments required for new technology, serious consideration should be given to address staff attitudes about privacy and technology in order to assure successful implementation.

Use of an EHR-Integrated Point-of-Care Mobile Medical Photography Application in a Pediatric Emergency Department.

BACKGROUND: Mobile applications allow health care providers to capture point-of-care medical photographs and transfer them to the electronic health record (EHR). It is unclear how providers use these photographs or how they affect clinical care. OBJECTIVES: We aimed to understand the content, purpose, and outcomes of point-of-care medical photography performed in the pediatric emergency department (ED) at large academic medical center. METHODS: A retrospective chart review was conducted of patients <21 years of age who were seen in the ED and photographed between March 29, 2015 and July 1, 2017 using a secure smartphone application integrated with the EHR. Inter-rater agreement and reliability between the two reviewers was assessed for the first 50 charts, and any discrepancies in interpretation were resolved before proceeding with the remaining data abstraction. The documented rationale for photography, content of photographs, and outcomes were recorded. RESULTS: We identified 619 clinical encounters involving photographs of 605 patients who were eligible for inclusion. Skin was photographed in 499 (81%). The most common finding was rash (N = 177; 29%). Photos were of acceptable quality, with 569 (94%) achieving a score between 4 and 5 out of 5. The primary use of photography was documentation (N = 334; 54%), though teleconsultation was noted in 38 (6%). Nearly one-third (N = 187; 30%) of patients were seen in the ED or outpatient clinic for any reason within 2 weeks, and in 25 (13%), clinical notes explicitly referenced the initial photograph(s). In 53 (9%) cases, patients were photographed at a clinical visit in the subsequent 2 weeks, suggesting that photography was used to track changes over time. CONCLUSION: Documentation of findings using mobile point-of-care photography allows for high-fidelity documentation and facilitates continuity of care.

Medical Videography Using a Mobile App: Retrospective Analysis.

BACKGROUND: As mobile devices and apps grow in popularity, they are increasingly being used by health care providers to aid clinical care. At our institution, we developed and implemented a point-of-care clinical photography app that also permitted the capture of video recordings; however, the clinical findings it was used to capture and the outcomes that resulted following video recording were unclear. OBJECTIVE: The study aimed to assess the use of a mobile clinical video recording app at our institution and its impact on clinical care. METHODS: A single reviewer retrospectively reviewed video recordings captured between April 2016 and July 2017, associated metadata, and patient records. RESULTS: We identified 362 video recordings that were eligible for inclusion. Most video recordings (54.1%; 190/351) were captured by attending physicians. Specialties recording a high number of video recordings included orthopedic surgery (33.7%; 122/362), neurology (21.3%; 77/362), and ophthalmology (15.2%; 55/362). Consent was clearly documented in the medical record in less than one-third (31.8%; 115/362) of the records. People other than the patient were incidentally captured in 29.6% (107/362) of video recordings. Although video recordings were infrequently referenced in notes corresponding to the clinical encounter (12.2%; 44/362), 7.7% (22/286) of patients were video recorded in subsequent clinical encounters, with 82% (18/22) of these corresponding to the same finding seen in the index video. Store-and-forward telemedicine was documented in clinical notes in only 2 cases (0.5%; 2/362). Videos appeared to be of acceptable quality for clinical purposes. CONCLUSIONS: Video recordings were captured in a variety of clinical settings. Documentation of consent was inconsistent, and other individuals were incidentally included in videos. Although clinical impact was not always clearly evident through retrospective review because of limited documentation, potential uses include documentation for future reference and store-and-forward telemedicine. Repeat video recordings of the same finding provide evidence of use to track the findings over time. Clinical video recordings have the potential to support clinical care; however, documentation of consent requires standardization.

Patient-Care Team Contact Patterns Impact Treatment Length of Stay in the Emergency Department.

Real-time location systems (RTLS) has found extensive application in the healthcare setting, that is shown to improve safety, save cost, and increase patient satisfaction. More specifically, some studies have shown the efficacy of RTLS leading to an improved workflow in the emergency department. However, due to substantial implementation costs of such technologies, hospital administrators show reluctance in RTLS adoption. Our previous preliminary studies with RFID data in the emergency department (ED) demonstrated for the first time the quantification of `patient alone time' and its relationship to outcomes such as 30-day hospitalization. In this study, we use ED RTLS data to analyze patient-care team contact time (PCTCT) and its relationship to the total treatment length of stay (LOS) in ED. An observational cohort study was performed in the ED using RTLS data from Jan 17 - Sep 17, 2017, which included a total of 51,697 patients. PCTCT within the first hour of a patient's placement in a treatment bed was calculated and its relationship to treatment LOS was analyzed while controlling for confounding factors affecting treatment LOS. Results show that treatment LOS is highly correlated with the ED crowding captured by the patient-perprovider ratio, negatively correlated to the physician and resident visit frequency, and positively correlated to nurse visit frequency. The results can inform designing new guidelines for ideal patient-care team interactions and be used to determine optimal ED staffing levels and care team composition for effective care delivery.

Anti-factor Xa Monitoring and Activated Charcoal for a Pediatric Patient With Rivaroxaban Overdose.

Rivaroxaban, an oral anticoagulant, directly inhibits factor Xa (FXa). A 35-month-old boy was brought to the emergency department 15 minutes after ingesting 200 mg of rivaroxaban (16 mg/kg). Activated charcoal (AC) was administered; the patient was observed with monitoring of plasma anti-FXa levels and discharged the following day after an uneventful hospital observation. We identified two case series and seven case reports of potentially toxic rivaroxaban ingestion in the literature. No serious adverse effects were reported. The present case is the first reported use of anti-FXa monitoring after rivaroxaban ingestion. The magnitude of the effect of AC administration in this patient is unclear.

PhotoExam: adoption of an iOS-based clinical image capture application at Mayo Clinic.

BACKGROUND: Mayo Clinic developed an internal iOS-based, point-of-care clinical image capture application for clinicians. We aimed to assess the adoption and utilization of the application at Mayo Clinic. METHODS: Metadata of 22,784 photos of 6417 patients taken by 606 users over 8040 clinical encounters between 3/1/2015 and 10/31/2015 were analyzed. A random sample of photos from 100 clinical encounters was assessed for quality using a five-item rubric. Use of traditional medical photography services before and after application launch were compared. RESULTS: The largest group of users was residents/fellows, accounting for 31% of users but only 18% of all photos. Attending physicians accounted for 29% of users and 30% of photos. Nurses accounted for 14% of users and 28% of photos. Surgical specialties had the most users (36% of users), followed by dermatology (14% of users); however, dermatology accounted for 54% of all photos, and surgery accounted for 26% of photos. Images received an average of 91% of possible points on the quality scoring rubric. Most frequent reasons for missing points were the location on the body not clearly being demonstrated (19% of encounters) and the perspective/scale not being clearly demonstrated (12% of encounters). There was no discernible pre-post effect of the application's launch on use of traditional medical photography services. CONCLUSIONS: Point-of-care clinical photography is a growing phenomenon with potential to become the new standard of care. Patient and provider attitudes and the impact on patient outcomes remain unclear.

Contact tracing with a real-time location system: A case study of increasing relative effectiveness in an emergency department.

BACKGROUND: Contact tracing is the systematic method of identifying individuals potentially exposed to infectious diseases. Electronic medical record (EMR) use for contact tracing is time-consuming and may miss exposed individuals. Real-time location systems (RTLSs) may improve contact identification. Therefore, the relative effectiveness of these 2 contact tracing methodologies were evaluated. METHODS: During a pertussis outbreak in the United States, a retrospective case study was conducted between June 14 and August 31, 2016, to identify the contacts of confirmed pertussis cases, using EMR and RTLS data in the emergency department of a tertiary care medical center. Descriptive statistics and a paired t test (α = 0.05) were performed to compare contacts identified by EMR versus RTLS, as was correlation between pertussis patient length of stay and the number of potential contacts. RESULTS: Nine cases of pertussis presented to the emergency department during the identified time period. RTLS doubled the potential exposure list (P < .01). Length of stay had significant positive correlation with contacts identified by RTLS (ρ = 0.79; P = .01) but not with EMR (ρ = 0.43; P = .25). CONCLUSIONS: RTLS doubled the potential pertussis exposures beyond EMR-based contact identification. Thus, RTLS may be a valuable addition to the practice of contact tracing and infectious disease monitoring.