Implementation, Maintenance, and Outcomes of an Electronic Referral to a Tobacco Quitline Across Five Health Systems.

INTRODUCTION: Electronic referral (e-referral) to quitlines helps connect tobacco-using patients to free, evidence-based cessation counseling. Little has been published about the real-world implementation of e-referrals across U.S. health systems, their maintenance over time, and the outcomes of e-referred patients. AIMS AND METHODS: Beginning in 2014, the University of California (UC)-wide project called UC Quits scaled up quitline e-referrals and related modifications to clinical workflows from one to five UC health systems. Implementation strategies were used to increase site readiness. Maintenance was supported through ongoing monitoring and quality improvement programs. Data on e-referred patients (n = 20 709) and quitline callers (n = 197 377) were collected from April 2014 to March 2021. Analyses of referral trends and cessation outcomes were conducted in 2021-2022. RESULTS: Of 20 709 patients referred, the quitline contacted 47.1%, 20.6% completed intake, 15.2% requested counseling, and 10.9% received it. In the 1.5-year implementation phase, 1813 patients were referred. In the 5.5-year maintenance phase, volume was sustained, with 3436 referrals annually on average. Among referred patients completing intake (n = 4264), 46.2% were nonwhite, 58.8% had Medicaid, 58.7% had a chronic disease, and 48.8% had a behavioral health condition. In a sample randomly selected for follow-up, e-referred patients were as likely as general quitline callers to attempt quitting (68.5% vs. 71.4%; p = .23), quit for 30 days (28.3% vs. 26.9%; p = .52), and quit for 6 months (13.6% vs. 13.9%; p = .88). CONCLUSIONS: With a whole-systems approach, quitline e-referrals can be established and sustained across inpatient and outpatient settings with diverse patient populations. Cessation outcomes were similar to those of general quitline callers. IMPLICATIONS: This study supports the broad implementation of tobacco quitline e-referrals in health care. To the best of our knowledge, no other paper has described the implementation of e-referrals across multiple U.S. health systems or how they were sustained over time. Modifying electronic health records systems and clinical workflows to enable and encourage e-referrals, if implemented and maintained appropriately, can be expected to improve patient care, make it easier for clinicians to support patients in quitting, increase the proportion of patients using evidence-based treatment, provide data to assess progress on quality goals, and help meet reporting requirements for tobacco screening and prevention.

The Impact of Inpatient Telemedicine on Personal Protective Equipment Savings During the COVID-19 Pandemic: Cross-sectional Study.

With the emergence of the COVID-19 pandemic and shortage of adequate personal protective equipment (PPE), hospitals implemented inpatient telemedicine measures to ensure operational readiness and a safe working environment for clinicians. The utility and sustainability of inpatient telemedicine initiatives need to be evaluated as the number of COVID-19 inpatients is expected to continue declining. In this viewpoint, we describe the use of a rapidly deployed inpatient telemedicine workflow at a large academic medical center and discuss the potential impact on PPE savings. In early 2020, videoconferencing software was installed on patient bedside iPads at two academic medical center teaching hospitals. An internal website allowed providers to initiate video calls with patients in any patient room with an activated iPad, including both COVID-19 and non-COVID-19 patients. Patients were encouraged to use telemedicine technology to connect with loved ones via native apps or videoconferencing software. We evaluated the use of telemedicine technology on patients' bedside iPads by monitoring traffic to the internal website. Between May 2020 and March 2021, there were a total of 1240 active users of the Video Visits website (mean 112.7, SD 49.0 connection events per month). Of these, 133 (10.7%) connections were made. Patients initiated 63 (47.4%) video calls with family or friends and sent 37 (27.8%) emails with videoconference connection instructions. Providers initiated a total of 33 (24.8%) video calls with the majority of calls initiated in August (n=22, 67%). There was a low level of adoption of inpatient telemedicine capability by providers and patients. With sufficient availability of PPE, inpatient providers did not find a frequent need to use the bedside telemedicine technology, despite a high census of patients with COVID-19. Compared to providers, patients used videoconferencing capabilities more frequently in September and October 2020. We did not find savings of PPE associated with the use of inpatient telemedicine.

Medical Undistancing Through Telemedicine: A Model Enabling Rapid Telemedicine Deployment in an Academic Health Center During the COVID-19 Pandemic.

Background: The authors draw upon their experience with a successful, enterprise-level, telemedicine program implementation to present a "How To" paradigm for other academic health centers that wish to rapidly deploy such a program in the setting of the COVID-19 pandemic. The advent of social distancing as essential for decreasing viral transmission has made it challenging to provide medical care. Telemedicine has the potential to medically undistance health care providers while maintaining the quality of care delivered and fulfilling the goal of social distancing. Methods: Rather than simply reporting enterprise telemedicine successes, the authors detail key telemedicine elements essential for rapid deployment of both an ambulatory and inpatient telemedicine solution. Such a deployment requires a multifaceted strategy: (1) determining the appropriateness of telemedicine use, (2) understanding the interface with the electronic health record, (3) knowing the equipment and resources needed, (4) developing a rapid rollout plan, (5) establishing a command center for post go-live support, (6) creating and disseminating reference materials and educational guides, (7) training clinicians, patients, and clinic schedulers, (8) considering billing and credentialing implications, (9) building a robust communications strategy, and (10) measuring key outcomes. Results: Initial results are reported, showing a telemedicine rate increase to 45.8% (58.6% video and telephone) in just the first week of rollout. Over a 5-month period, the enterprise has since conducted over 119,500 ambulatory telemedicine evaluations (a 1,000-fold rate increase from the pre-COVID-19 time period). Conclusion: This article is designed to offer a "How To" potential best practice approach for others wishing to quickly implement a telemedicine program during the COVID-19 pandemic.

Public Health Role of Academic Medical Center in Community Outbreak of Hepatitis A, San Diego County, California, USA, 2016-2018.

During 2016-2018, San Diego County, California, USA, experienced one of the largest hepatitis A outbreaks in the United States in 2 decades. In close partnership with local healthcare systems, San Diego County Public Health led a public health response to the outbreak that focused on a 3-pronged strategy to vaccinate, sanitize, and educate. Healthcare systems administered nearly half of the vaccinations delivered in San Diego County. At University of California San Diego Health, the use of informatics tools assisted with the identification of at-risk populations and with vaccine delivery across outpatient and inpatient settings. In addition, acute care facilities helped prevent further disease transmission by delaying the discharge of patients with hepatitis A who were experiencing homelessness. We assessed the public health roles that acute care hospitals can play during a large community outbreak and the critical nature of ongoing collaboration between hospitals and public health systems in controlling such outbreaks.

Using an online quiz-based reinforcement system to teach healthcare quality and patient safety and care transitions at the University of California.

QUALITY ISSUE: Implementing quality improvement (QI) education during clinical training is challenging due to time constraints and inadequate faculty development in these areas. INITIAL ASSESSMENT: Quiz-based reinforcement systems show promise in fostering active engagement, collaboration, healthy competition and real-time formative feedback, although further research on their effectiveness is required. CHOICE OF SOLUTION: An online quiz-based reinforcement system to increase resident and faculty knowledge in QI, patient safety and care transitions. IMPLEMENTATION: Experts in QI and educational assessment at the 5 University of California medical campuses developed a course comprised of 3 quizzes on Introduction to QI, Patient Safety and Care Transitions. Each quiz contained 20 questions and utilized an online educational quiz-based reinforcement system that leveraged spaced learning. EVALUATION: Approximately 500 learners completed the course (completion rate 66-86%). Knowledge acquisition scores for all quizzes increased after completion: Introduction to QI (35-73%), Patient Safety (58-95%), and Care Transitions (66-90%). Learners reported that the quiz-based system was an effective teaching modality and preferred this type of education to classroom-based lectures. Suggestions for improvement included reducing frequency of presentation of questions and utilizing more questions that test learners on application of knowledge instead of knowledge acquisition. LESSONS LEARNED: A multi-campus online quiz-based reinforcement system to train residents in QI, patient safety and care transitions was feasible, acceptable, and increased knowledge. The course may be best utilized to supplement classroom-based and experiential curricula, along with increased attention to optimizing frequency of presentation of questions and enhancing application skills.

Transfusing Wisely: Clinical Decision Support Improves Blood Transfusion Practices.

BACKGROUND: The cost and risks of red blood cell (RBC) transfusions, along with evidence of overuse, suggest that improving transfusion practices is a key opportunity for health systems to improve both the quality and value of patient care. Previous work, which included a BestPractice Advisory (BPA), was adapted in a quality improvement project designed to reduce both exposure to unnecessary blood products and costs. METHODS: A prospective, pre-post study was conducted at an academic medical center with a diverse patient population. All noninfant inpatients without gastrointestinal bleeding who were not within 12 hours of surgical procedures were included. The interventions were education, a BPA, and other enhancements to the computerized provider order entry system. RESULTS: The percentage of multiunit (≥ 2 units) RBC transfusions decreased from 59.9% to 41.7% during the intervention period and to 19.7% postintervention (p < 0.0001). The percentage of inpatient RBC transfusion units administered for hemoglobin (Hb) ≥ 7 g/dL declined from 72.3% to 57.8% during the intervention period and to 38.0% for the postintervention period (p < 0.0001). The overall rate of inpatient RBC transfusion (units administered per 1,000 patient-days without exclusions) decreased from 89.8 to 78.1 during the intervention period and to 72.7 during the postintervention period (p <0.0001). The estimated annual cost savings was $1,050,750. CONCLUSION: The interventions reduced multiunit transfusions (by 67.1%) and transfusions for Hb ≥ 7 g/dL (by 47.4%). The improvement in the overall transfusion rate (19.0%) was less marked, limited by better baseline performance relative to other centers.

Impact of a hypoglycemia reduction bundle and a systems approach to inpatient glycemic management.

OBJECTIVE: Uncontrolled hyperglycemia and iatrogenic hypoglycemia represent common and frequently preventable quality and safety issues. We sought to demonstrate the effectiveness of a hypoglycemia reduction bundle, proactive surveillance of glycemic outliers, and an interdisciplinary data-driven approach to glycemic management. POPULATION: all hospitalized adult non-intensive care unit (non-ICU) patients with hyperglycemia and/or a diagnosis of diabetes admitted to our 550-bed academic center across 5 calendar years (CYs). INTERVENTIONS: hypoglycemia reduction bundle targeting most common remediable contributors to iatrogenic hypoglycemia; clinical decision support in standardized order sets and glucose management pages; measure-vention (daily measurement of glycemic outliers with concurrent intervention by the inpatient diabetes team); educational programs. MEASURES AND ANALYSIS: Pearson chi-square value with relative risks (RRs) and 95% confidence intervals (CIs) were calculated to compare glycemic control, hypoglycemia, and hypoglycemia management parameters across the baseline time period (TP1, CY 2009-2010), transitional (TP2, CY 2011-2012), and mature postintervention phase (TP3, CY 2013). Hypoglycemia defined as blood glucose <70 mg/dL, severe hypoglycemia as <40 mg/dL, and severe hyperglycemia >299 mg/dL. RESULTS: A total of 22,990 non-ICU patients, representing 94,900 patient-days of observation were included over the 5-year study. The RR TP3:TP1 for glycemic excursions was reduced significantly: hypoglycemic stay, 0.71 (95% CI, 0.65 to 0.79); severe hypoglycemic stay, 0.44 (95% CI, 0.34 to 0.58); recurrent hypoglycemic day during stay, 0.78 (95% CI, 0.64 to 0.94); severe hypoglycemic day, 0.48 (95% CI, 0.37 to 0.62); severe hyperglycemic day (>299 mg/dL), 0.76 (95% CI, 0.73 to 0.80). CONCLUSION: Hyperglycemia and hypoglycemia event rates were both improved, with the most marked effect on severe hypoglycemic events. Most of these interventions should be portable to other hospitals.

COAST (Coordinating Options for Acute Stroke Therapy): An Advance Directive for Stroke.

BACKGROUND: Stroke is a worldwide problem with a limited number of approved treatments. Obtaining informed consent for acute stroke therapy is complicated by the breadth of information that must be communicated in a short period of time, the hectic nature of the emergency environment, the possible lack of understanding by the patient and/or family, and the critically time-sensitive nature of treatment for stroke. Complicating matters even further, patients are often unable to consent for themselves, placing the burden on surrogates to infer patients' wishes regarding treatment, and potentially limiting acute treatment by practitioners. INNOVATION: An advance directive for acute stroke therapy was created, entitled COAST (Coordinating Options for Acute Stroke Therapy). This clinical initiative is being piloted at a large comprehensive stroke center, including the development of the advance directive form, integration of the form with electronic medical records, training healthcare providers, and outreach to patients. CONCLUSIONS: COAST is an advance directive for stroke designed to make stroke care more efficient, optimize patients' autonomy, improve the quality of healthcare, and streamline the ethical management of complex care decisions in acute stroke. The inherent benefit of COAST is in providing patients and their families with more information regarding stroke and its treatment options, allowing them to take a more active role in their care.

Ultrasonography Leads to Accurate Diagnosis and Management of Painful Acromioclavicular Joint Cyst.

BACKGROUND: Acromioclavicular joint (ACJ) cysts are uncommon causes of shoulder pain. Type 1 ACJ cysts are limited to the ACJ and form in the presence of intact rotator cuff musculature, while type 2 cysts form secondary to biomechanical instability following rotator cuff tear or rupture. CASE PRESENTATION: A 36-year-old overweight male with history of chronic left grade 2 (Rockwood classification) ACJ separation presented with intermittent pain at the distal superoanterior left clavicle. Physical examination revealed small step off at the ACJ and multiple subcutaneous cysts surrounding the ACJ. Ultrasound examination revealed a mild separation of the left ACJ, mild distension of the joint capsule, and a small, well-circumscribed, compressible hypo-echoic cyst overlying the clavicle. Palpation of the cyst against the clavicle reproduced the patient's symptoms of intermittent pain. He opted for ultrasound-guided aspiration and subsequently had full resolution of his symptoms. DISCUSSION: Musculoskeletal ultrasound is useful for diagnosis and management of refractory musculoskeletal conditions that are commonly misdiagnosed on physical examination and translucent to radiographic imaging. Musculoskeletal ultrasound allowed us to exclude rotator cuff pathology, identify ACJ cyst as the pain generator, classify it as a type 1 ACJ cyst, and aid in needle guidance for successful aspiration leading to full resolution of our patient's pain.

Using a triggered endocrinology service consultation to improve the evaluation, management, and follow-up of osteoporosis in hip-fracture patients.

BACKGROUND: Nearly 2 million osteoporosis-related fractures occur yearly in the United States, with more than 400,000 requiring hospital admissions. Fewer than 30% receive proper evaluation and care for osteoporosis, representing a large opportunity to enhance secondary prevention of fractures. Methods to improve identification and triage of hospitalized fragility-fracture patients are desirable. METHODS: A multidisciplinary team was created, and definitions were established for an evidence-based best-practice protocol to assess, treat, and document an osteoporosis diagnosis and triage patients with hip-fragility fractures on the basis of the best-practice recommendations from The Joint Commission and the National Osteoporosis Foundation. The team initiated a preauthorized osteoporosis consultation from the endocrinology service for hip-fracture patients, "triggered" via a brief query in admission orders or by the orthopedic service nurse practitioner. Osteoporosis consultations used a consultation template reflecting the protocol. RESULTS: Data were analyzed for 71 baseline patients and 61 intervention patients. The groups possessed similar age, gender, race, and body mass index characteristics. The baseline (on-demand consultation) group suffered from poor performance, with only 3%-21% of patients receiving the desired evaluation, documentation, treatment, or outpatient follow-up. Intervention (triggered-consultation) patients improved markedly postintervention, With performance increasing by 52%-76% on all parameters except outpatient follow-up, which changed insignificantly (6%-15%). CONCLUSION: Although triggered consultation was effective, multimodal layered interventions may achieve even better results and address several identified barriers.

Implementation of an electronic health record-integrated instant messaging system in an academic health system.

OBJECTIVES: Effective communication amongst healthcare workers simultaneously promotes optimal patient outcomes when present and is deleterious to outcomes when absent. The advent of electronic health record (EHR)-embedded secure instantaneous messaging systems has provided a new conduit for provider communication. This manuscript describes the experience of one academic medical center with deployment of one such system (Secure Chat). METHODS: Data were collected on Secure Chat message volume from June 2017 to April 2023. Significant perideployment events were reviewed chronologically. RESULTS: After the first coronavirus disease 2019 lockdown in March 2020, messaging use increased by over 25 000 messages per month, with 1.2 million messages sent monthly by April 2023. Comparative features of current communication modalities in healthcare were summarized, highlighting the many advantages of Secure Chat. CONCLUSIONS: While EHR-embedded secure instantaneous messaging systems represent a novel and potentially valuable communication medium in healthcare, generally agreed-upon best practices for their implementation are, as of yet, undetermined.

An Automated System for Physician Trainee Procedure Logging via Electronic Health Records.

Importance: Procedural proficiency is a core competency for graduate medical education; however, procedural reporting often relies on manual workflows that are duplicative and generate data whose validity and accuracy are difficult to assess. Failure to accurately gather these data can impede learner progression, delay procedures, and negatively impact patient safety. Objective: To examine accuracy and procedure logging completeness of a system that extracts procedural data from an electronic health record system and uploads these data securely to an application used by many residency programs for accreditation. Design, Setting, and Participants: This quality improvement study of all emergency medicine resident physicians at University of California, San Diego Health was performed from May 23, 2023, to June 25, 2023. Exposures: Automated system for procedure data extraction and upload to a residency management software application. Main Outcomes and Measures: The number of procedures captured by the automated system when running silently compared with manually logged procedures in the same timeframe, as well as accuracy of the data upload. Results: Forty-seven residents participated in the initial silent assessment of the extraction component of the system. During a 1-year period (May 23, 2022, to May 7, 2023), 4291 procedures were manually logged by residents, compared with 7617 procedures captured by the automated system during the same period, representing a 78% increase. During assessment of the upload component of the system (May 8, 2023, to June 25, 2023), a total of 1353 procedures and patient encounters were evaluated, with the system operating with a sensitivity of 97.4%, specificity of 100%, and overall accuracy of 99.5%. Conclusions and Relevance: In this quality improvement study of emergency medicine resident physicians, an automated system demonstrated that reliance on self-reported procedure logging resulted in significant procedural underreporting compared with the use of data obtained at the point of performance. Additionally, this system afforded a degree of reliability and validity heretofore absent from the usual after-the-fact procedure logging workflows while using a novel application programming interface-based approach. To our knowledge, this system constitutes the first generalizable implementation of an automated solution to a problem that has existed in graduate medical education for decades.

Ransomware Attack Associated With Disruptions at Adjacent Emergency Departments in the US.

Importance: Cyberattacks on health care delivery organizations are increasing in frequency and sophistication. Ransomware infections have been associated with significant operational disruption, but data describing regional associations of these cyberattacks with neighboring hospitals have not been previously reported, to our knowledge. Objective: To examine an institution's emergency department (ED) patient volume and stroke care metrics during a month-long ransomware attack on a geographically proximal but separate health care delivery organization. Design, Setting, and Participants: This before and after cohort study compares adult and pediatric patient volume and stroke care metrics of 2 US urban academic EDs in the 4 weeks prior to the ransomware attack on May 1, 2021 (April 3-30, 2021), as well as during the attack and recovery (May 1-28, 2021) and 4 weeks after the attack and recovery (May 29 to June 25, 2021). The 2 EDs had a combined mean annual census of more than 70 000 care encounters and 11% of San Diego County's total acute inpatient discharges. The health care delivery organization targeted by the ransomware constitutes approximately 25% of the regional inpatient discharges. Exposure: A month-long ransomware cyberattack on 4 adjacent hospitals. Main Outcomes and Measures: Emergency department encounter volumes (census), temporal throughput, regional diversion of emergency medical services (EMS), and stroke care metrics. Results: This study evaluated 19 857 ED visits at the unaffected ED: 6114 (mean [SD] age, 49.6 [19.3] years; 2931 [47.9%] female patients; 1663 [27.2%] Hispanic, 677 [11.1%] non-Hispanic Black, and 2678 [43.8%] non-Hispanic White patients) in the preattack phase, 7039 (mean [SD] age, 49.8 [19.5] years; 3377 [48.0%] female patients; 1840 [26.1%] Hispanic, 778 [11.1%] non-Hispanic Black, and 3168 [45.0%] non-Hispanic White patients) in the attack and recovery phase, and 6704 (mean [SD] age, 48.8 [19.6] years; 3326 [49.5%] female patients; 1753 [26.1%] Hispanic, 725 [10.8%] non-Hispanic Black, and 3012 [44.9%] non-Hispanic White patients) in the postattack phase. Compared with the preattack phase, during the attack phase, there were significant associated increases in the daily mean (SD) ED census (218.4 [18.9] vs 251.4 [35.2]; P < .001), EMS arrivals (1741 [28.8] vs 2354 [33.7]; P < .001), admissions (1614 [26.4] vs 1722 [24.5]; P = .01), patients leaving without being seen (158 [2.6] vs 360 [5.1]; P < .001), and patients leaving against medical advice (107 [1.8] vs 161 [2.3]; P = .03). There were also significant associated increases during the attack phase compared with the preattack phase in median waiting room times (21 minutes [IQR, 7-62 minutes] vs 31 minutes [IQR, 9-89 minutes]; P < .001) and total ED length of stay for admitted patients (614 minutes [IQR, 424-1093 minutes] vs 822 minutes [IQR, 497-1524 minutes]; P < .001). There was also a significant increase in stroke code activations during the attack phase compared with the preattack phase (59 vs 102; P = .01) as well as confirmed strokes (22 vs 47; P = .02). Conclusions and Relevance: This study found that hospitals adjacent to health care delivery organizations affected by ransomware attacks may see increases in patient census and may experience resource constraints affecting time-sensitive care for conditions such as acute stroke. These findings suggest that targeted hospital cyberattacks may be associated with disruptions of health care delivery at nontargeted hospitals within a community and should be considered a regional disaster.

Surgery and Anesthesia Preoperative "Virtual Huddle": A Pilot Trial to Enhance Communication across the Drape.

OBJECTIVES: Effective communication between surgeons and anesthesiologists is critical for high-quality, safe, and efficient perioperative patient care. Despite widespread implementation of surgical safety checklists and time-outs, ineffective team communication remains a leading cause of patient safety events in the operating room. To promote effective communication, we conducted a pilot trial of a "virtual huddle" between anesthesiologists and surgeons. METHODS: Attending anesthesiologists and surgeons at an academic medical center were recruited by email to participate in this feasibility trial. An electronic health record-based smartphone application was utilized to create secure group chats among trial participants the day before a surgery. Text notifications connected a surgeon/anesthesiologist pair in order to introduce colleagues, facilitate a preoperative virtual huddle, and enable open-ended, text message-based communication. A 5-point Likert scale-based survey with a free-text component was used to evaluate the utility of the virtual huddle and usability of the electronic platform. RESULTS: A total of 51 unique virtual huddles occurred between 16 surgeons and 12 anesthesiologists over 99 operations. All postintervention survey questions received a positive rating (range: 3.50/5.00-4.53/5.00) and the virtual huddle was considered to be easy to use (4.47/5.00), improve attending-to-attending communication (4.29/5.00), and improve patient care (4.22/5.00). There were no statistically significant differences in the ratings between surgery and anesthesia. In thematic analysis of qualitative survey results, Participants indicated the intervention was particularly useful in interdisciplinary relationship-building and reducing room turnover. The huddle was less useful for simple, routine cases or when participation was one sided. CONCLUSION: A preoperative virtual huddle may be a simple and effective intervention to improve communication and teamwork in the operating room. Further study and consideration of broader implementation is warranted.

Association of physician burnout with perceived EHR work stress and potentially actionable factors.

OBJECTIVE: Physicians of all specialties experienced unprecedented stressors during the COVID-19 pandemic, exacerbating preexisting burnout. We examine burnout's association with perceived and actionable electronic health record (EHR) workload factors and personal, professional, and organizational characteristics with the goal of identifying levers that can be targeted to address burnout. MATERIALS AND METHODS: Survey of physicians of all specialties in an academic health center, using a standard measure of burnout, self-reported EHR work stress, and EHR-based work assessed by the number of messages regarding prescription reauthorization and use of a staff pool to triage messages. Descriptive and multivariable regression analyses examined the relationship among burnout, perceived EHR work stress, and actionable EHR work factors. RESULTS: Of 1038 eligible physicians, 627 responded (60% response rate), 49.8% reported burnout symptoms. Logistic regression analysis suggests that higher odds of burnout are associated with physicians feeling higher level of EHR stress (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.07-1.25), having more prescription reauthorization messages (OR, 1.23; 95% CI, 1.04-1.47), not feeling valued (OR, 3.38; 95% CI, 1.69-7.22) or aligned in values with clinic leaders (OR, 2.81; 95% CI, 1.87-4.27), in medical practice for ≤15 years (OR, 2.57; 95% CI, 1.63-4.12), and sleeping for <6 h/night (OR, 1.73; 95% CI, 1.12-2.67). DISCUSSION: Perceived EHR stress and prescription reauthorization messages are significantly associated with burnout, as are non-EHR factors such as not feeling valued or aligned in values with clinic leaders. Younger physicians need more support. CONCLUSION: A multipronged approach targeting actionable levers and supporting young physicians is needed to implement sustainable improvements in physician well-being.

Surgical pit crew: initiative to optimise measurement and accountability for operating room turnover time.

BACKGROUND AND OBJECTIVES: Turnover time (TOT), defined as the time between surgical cases in the same operating room (OR), is often perceived to be lengthy without clear cause. With the aim of optimising and standardising OR turnover processes and decreasing TOT, we developed an innovative and staff-interactive TOT measurement method. METHODS: We divided TOT into task-based segments and created buttons on the electronic health record (EHR) default prelogin screen for appropriate staff workflows to collect more granular data. We created submeasures, including 'clean-up start', 'clean-up complete', 'set-up start' and 'room ready for patient', to calculate environmental services (EVS) response time, EVS cleaning time, room set-up response time, room set-up time and time to room accordingly. RESULTS: Since developing and implementing these workflows, measures have demonstrated excellent staff adoption. Median times of EVS response and cleaning have decreased significantly at our main hospital ORs and ambulatory surgery centre. CONCLUSION: OR delays are costly to hospital systems. TOT, in particular, has been recognised as a potential dissatisfier and cause of delay in the perioperative environment. Viewing TOT as one finite entity and not a series of necessary tasks by a variety of team members limits the possibility of critical assessment and improvement. By dividing the measurement of TOT into respective segments necessary to transition the room at the completion of one case to the onset of another, valuable insight was gained into the causes associated with turnover delays, which increased awareness and improved accountability of staff members to complete assigned tasks efficiently.

Comparing the Use of DynaMed and UpToDate by Physician Trainees in Clinical Decision-Making: A Randomized Crossover Trial.

BACKGROUND: Costs vary substantially among electronic medical knowledge resources used for clinical decision support, warranting periodic assessment of institution-wide adoption. OBJECTIVES: To compare two medical knowledge resources, UpToDate and DynaMed Plus, regarding accuracy and time required to answer standardized clinical questions and user experience. METHODS: A crossover trial design was used, wherein physicians were randomized to first use one of the two medical knowledge resources to answer six standardized questions. Following use of each resource, they were surveyed regarding their user experience. The percentage of accurate answers and time required to answer each question were recorded. The surveys assessed ease of use, enjoyment using the resource, quality of information, and ability to assess level of evidence. Tests of carry-over effects were performed. Themes were identified within open-ended survey comments regarding overall user experience. RESULTS: Among 26 participating physicians, accuracy of answers differed by 4 percentage points or less. For all but one question, there were no significant differences in the time required for completion. Most participants felt both resources were easy to use, contained high quality of information, and enabled assessment of the level of evidence. A greater proportion of participants endorsed enjoyment of use with UpToDate (23/26, 88%) compared with DynaMed Plus (16/26, 62%). Themes from open-ended comments included interface/information presentation, coverage of clinical topics, search functions, and utility for clinical decision-making. The majority (59%) of open-ended comments expressed an overall preference for UpToDate, compared with 19% preferring DynaMed Plus. CONCLUSION: DynaMed Plus is noninferior to UpToDate with respect to ability to achieve accurate answers, time required for answering clinical questions, ease of use, quality of information, and ability to assess level of evidence. However, user experience was more positive with UpToDate. Future studies of electronic medical knowledge resources should continue to emphasize evaluation of usability and user experience.

A Novel Fellowship in Perioperative Administration, Quality and Informatics: A Pilot Experience for Training Surgical Leaders.

Value-based, outcome-oriented care supported with innovative technology is the future of surgery. We established a novel fellowship in Perioperative Administration, Quality, and Informatics. The aim is to equip future surgeon scholars with the requisite knowledge base and skillset to serve as institutional leaders capable of transforming surgical healthcare delivery. The model was designed as a project-based, "operations-focused" education with supplemental didactics and mentored by surgical leaders and institutional executives. We describe our initial experience, successes, and challenges such that a similar model may be replicated elsewhere.