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Introduction: Telehealth has emerged as an important clinical setting for managing acute respiratory tract infections (ARIs), potentially reducing emergency department and urgent care overcrowding, and reducing nosocomial transmission. Many current algorithms for ARI management incorporate information on patient vital signs. However, the accuracy of vital signs collected by patients using readily available home devices and techniques has not been studied. Methods: A cross-sectional sample of patients seen for urgent conditions at a hospital emergency and urgent care center were given instructions and low-cost, readily available devices to collect their vital signs. A trained research coordinator collected a parallel set of vital signs using standard hospital equipment, serving as the gold standard. We analyzed the performance of patient-collected vital signs compared with vital signs collected by a trained research coordinator. Results: A total of 300 patients completed the study. Patient-collected vital signs were highly specific for traditional levels of abnormalities (HR >100 beats per min, RR >24 breaths per min, temperature >100.4 degrees Fahrenheit, oxygen saturation <94 percent); however, sensitivity was poor for elevated heart rate by pulse estimation (25%) and elevated respiratory rate (60%). Heart rate and oxygen saturation by pulse oximeter and oral temperature had higher sensitivity. Conclusions: Vital signs measured and provided by patients are not uniformly accurate, particularly when using manual techniques rather than automated devices. Telehealth algorithms that rely on these values could provide incorrect triage and management advice.
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Monitoring the average daily census (ADC) is crucial for managing patient flow and allocating resources. This study analyzed hourly fluctuations in the ADC on a hospital medicine service at an academic medical center. Data from 8342 encounters and 6178 unique patients were collected over a year. The ADC peaked at 11 a.m. (164.1 patients/day) and was lowest at 7 p.m. (155.0 patients/day), accounting for a variation of up to 9.1 patients (5.5% of peak census) depending on the time of day the measurement was taken. Understanding how ADC changes throughout the day will help hospital medicine programs to partner with administrators to optimize resource allocation and staffing. Measuring ADC at midnight, as traditionally done, may underestimate workload and therefore contribute to staffing shortages and physician burnout. Hospitals should consider measuring ADC at its peak, between 7 a.m. and 11 a.m., to ensure adequate staffing and high-quality patient care.
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Medicina Hospitalar , Humanos , Censos , Carga de Trabajo , Hospitales , Recursos Humanos , Admisión y Programación de PersonalRESUMEN
Vascular smooth muscle cell (VSMC) tone is regulated by the state of myosin light chain (MLC) phosphorylation, which is in turn regulated by the balance between MLC kinase and MLC phosphatase (MLCP) activities. RhoA activates Rho kinase, which phosphorylates the regulatory subunit of MLC phosphatase, thereby inhibiting MLC phosphatase activity and increasing contraction and vascular tone. Nitric oxide is an important mediator of VSMC relaxation and vasodilation, which acts by increasing cyclic GMP (cGMP) levels in VSMC, thereby activating cGMP-dependent protein kinase Iα (PKGIα). PKGI is known to phosphorylate Rho kinase, preventing Rho-mediated inhibition of MLC phosphatase, promoting vasorelaxation, although the molecular mechanisms that mediate this are unclear. Here we identify RhoA as a target of activated PKGIα and show further that PKGIα binds directly to RhoA, inhibiting its activation and translocation. In protein pulldown and immunoprecipitation experiments, binding of RhoA and PKGIα was demonstrated via a direct interaction between the amino terminus of RhoA (residues 1-44), containing the switch I domain of RhoA, and the amino terminus of PKGIα (residues 1-59), which includes a leucine zipper heptad repeat motif. Affinity assays using cGMP-immobilized agarose showed that only activated PKGIα binds RhoA, and a leucine zipper mutant PKGIα was unable to bind RhoA even if activated. Furthermore, a catalytically inactive mutant of PKGIα bound RhoA but did not prevent RhoA activation and translocation. Collectively, these results support that RhoA is a PKGIα target and that direct binding of activated PKGIα to RhoA is central to cGMP-mediated inhibition of the VSMC Rho kinase contractile pathway.
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Proteína Quinasa Dependiente de GMP Cíclico Tipo I/metabolismo , Regulación de la Expresión Génica , Proteínas de Unión al GTP rho/metabolismo , Proteína de Unión al GTP rhoA/metabolismo , Células 3T3 , Secuencias de Aminoácidos , Animales , Aorta/metabolismo , Células COS , Chlorocebus aethiops , Células Endoteliales/citología , Humanos , Hipertensión/metabolismo , Ratones , Modelos Biológicos , Unión Proteica , Transducción de Señal , Fracciones Subcelulares/metabolismo , Quinasas Asociadas a rho/metabolismoRESUMEN
BACKGROUND: An estimated 1,500 operations result in retained surgical items (RSIs) each year in the United States, resulting in substantial morbidity. The rarity of these events makes studying them difficult, but miscount incidents may provide a window into understanding risk factors for RSIs. METHODS: A cohort study of all consecutive operative cases during a 12-month period was conducted at a large academic medical center to identify risk factors for surgical miscounts. A multidisciplinary electronic miscount reconciliation checklist (necessitating both surgeon and nurse input) was introduced into the internally developed electronic Perioperative Information Management System to build a predictive model for RSI cases. RESULTS: Among 23,955 operations, 84 resulted in miscount incidents (0.35% [95% confidence interval: 0.28% to 0.43%]). Increased case duration was strongly associated with increased risk of a miscount in unadjusted analyses (p < .0001). In the nested case-control analysis, both the case duration and the number of providers present were independently associated with a more than doubling of the odds of a miscount, even after adjustment for one another, the elective/urgent/emergent status of a case, and personnel changes occurring during the case. CONCLUSIONS: The finding that both the length of the case and the number of providers involved in the case were independent risk factors for miscount incidents may offer insight into risk-targeted strategies to prevent RSIs, such as postoperative imaging, bar-coded surgical items, and radiofrequency technology. Miscounts trigger use of the Incorrect Count Safety Checklist, which can be used to determine whether a count completed at the procedure's conclusion is consistent across disciplines (circulating nurses, scrub persons, surgeons).
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Centros Médicos Académicos/estadística & datos numéricos , Cuerpos Extraños/clasificación , Cuerpos Extraños/epidemiología , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Factores de Edad , Estudios de Cohortes , Humanos , Personal de Hospital/estadística & datos numéricos , Calidad de la Atención de Salud , Factores de Riesgo , Factores de Tiempo , Estados UnidosRESUMEN
BACKGROUND: Electronic visits (e-visits) are billable, asynchronous patient-initiated messages that require at least five minutes of medical decision-making by a provider. Unequal use of patient portal tools like e-visits by certain patient populations may worsen health disparities. To date, no study has attempted to qualitatively assess perceptions of e-visits in older adults. OBJECTIVE: In this qualitative study, we aimed to understand patient perceptions of e-visits, including their perceived utility, barriers to use, and care implications, with a focus on vulnerable patient groups. METHODS: We conducted a qualitative study using in-depth structured individual interviews with patients from diverse backgrounds to assess their knowledge and perceptions surrounding e-visits as compared with unbilled portal messages and other visit types. We used content analysis to analyze interview data. RESULTS: We conducted 20 interviews, all in adults older than 65 years. We identified 4 overarching coding categories or themes. First, participants were generally accepting of the concept of e-visits and willing to try them. Second, nearly two-thirds of the participants voiced a preference for synchronous communication. Third, participants had specific concerns about the name "e-visit" and when to choose this type of visit in the patient portal. Fourth, some participants indicated discomfort using or accessing technology for e-visits. Financial barriers to the use of e-visits was not a common theme. CONCLUSIONS: Our findings suggest that older adults are generally accepting of the concept of e-visits, but uptake may be limited due to their preference for synchronous communication. We identified several opportunities to improve e-visit implementation.
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PURPOSE: In an effort to decrease transmission during the first years of the COVID-19 pandemic, public health officials encouraged masking, social distancing, and working from home, and restricted travel. However, many studies of the effectiveness of these measures had significant methodologic limitations. In this analysis, we used data from the TrackCOVID study, a longitudinal cohort study of a population-based sample of 3846 adults in the San Francisco Bay Area, to evaluate the association between self-reported protective behaviors and incidence of SARS-CoV-2 infection. METHODS: Participants without SARS-CoV2 infection were enrolled from August to December 2020 and followed monthly with testing and surveys (median of four visits). RESULTS: A total of 118 incident infections occurred (3.0% of participants). At baseline, 80.0% reported always wearing a mask; 56.0% avoided contact with nonhousehold members some/most of the time; 9.6% traveled outside the state; and 16.0% worked 20 or more hours per week outside the home. Factors associated with incident infection included being Black or Latinx, having less than a college education, and having more household residents. The only behavioral factor associated with incident infection was working outside the home (adjusted hazard ratio 1.62, 95% confidence interval 1.02-2.59). CONCLUSIONS: Focusing on protecting people who cannot work from home could help prevent infections during future waves of COVID-19, or future pandemics from respiratory viruses. This focus must be balanced with the known importance of directing resources toward those at risk of severe infections.
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COVID-19 , Adulto , Humanos , COVID-19/epidemiología , COVID-19/prevención & control , SARS-CoV-2 , Pandemias/prevención & control , Estudios Longitudinales , ARN Viral , San Francisco/epidemiología , Estudios de CohortesRESUMEN
DRIVING FORCES: Traditional specialty consults are resource intensive and may be delayed or omitted if the treating physician does not recognize the need for specialty advice. Targeted automatic e-consults (TACos) address these limitations by prospectively identifying patients using the electronic health record (EHR) and presenting pertinent information on a dashboard, enabling consultants to provide a virtual consult with written recommendations. The TACo model may improve value by facilitating more expert input without a proportional increase in cost. BUILDING A TACO: Through our experience developing a TACo program, we have identified four key steps. First, identify appropriate conditions that have support from the health system and from frontline clinicians. Second, design the digital infrastructure, including lists and dashboards. Third, create a funding plan to support the consultant's time, either through internal grants, external grants, e-consult billing codes, or some combination of the three. Fourth, pilot on a select number of services, iterate, and scale. CHALLENGES: Funding for TACos has been a major barrier to adoption. Fortunately, new e-consult billing codes may make it possible to recoup as least part of the program's cost. Technological hurdles also exist, particularly in building real-time lists within the EHR to prospectively identify patients based on complex criteria. NEXT STEPS: We look for this model to gain popularity as evidence of clinical and operational benefit mounts. We anticipate reimbursement policies may be updated to support this type of consult. Finally, we expect machine learning to play a role in identifying patients and providing recommendations in the future.
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Registros Electrónicos de Salud , Derivación y Consulta , HumanosRESUMEN
OBJECTIVE: Symptom checkers can help address high demand for SARS-CoV2 (COVID-19) testing and care by providing patients with self-service access to triage recommendations. However, health systems may be hesitant to invest in these tools, as their associated efficiency gains have not been studied. We aimed to quantify the operational efficiency gains associated with use of an online COVID-19 symptom checker as an alternative to a telephone hotline. METHODS: In our health system, ambulatory patients can either use an online symptom checker or a telephone hotline to be triaged and connected to COVID-19 care. We performed a retrospective analysis of adults who used either method between October 20, 2021 and January 10, 2022, using call logs, electronic health record data, and local wages to calculate labor costs. RESULTS: Of the 15â549 total COVID-19 triage encounters, 1820 (11.7%) used only the telephone hotline and 13â729 (88.3%) used the symptom checker. Only 271 (2%) of the patients who used the symptom checker also called the hotline. Hotline encounters required more clinician time compared to those involving the symptom checker (17.8 vs 0.4 min/encounter), resulting in higher average labor costs ($24.21 vs $0.55 per encounter). The symptom checker resulted in over 4200 clinician labor hours saved. CONCLUSION: When given the option, most patients completed COVID-19 triage and visit scheduling online, resulting in substantial efficiency gains. These benefits may encourage health system investment in such tools.
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COVID-19 , Adulto , Humanos , Triaje/métodos , SARS-CoV-2 , Estudios Retrospectivos , ARN ViralRESUMEN
BACKGROUND: Symptom checkers have been widely used during the COVID-19 pandemic to alleviate strain on health systems and offer patients a 24-7 self-service triage option. Although studies suggest that users may positively perceive web-based symptom checkers, no studies have quantified user feedback after use of an electronic health record-integrated COVID-19 symptom checker with self-scheduling functionality. OBJECTIVE: In this paper, we aimed to understand user experience, user satisfaction, and user-reported alternatives to the use of a COVID-19 symptom checker with self-triage and self-scheduling functionality. METHODS: We launched a patient-portal-based self-triage and self-scheduling tool in March 2020 for patients with COVID-19 symptoms, exposures, or questions. We made an optional, anonymous Qualtrics survey available to patients immediately after they completed the symptom checker. RESULTS: Between December 16, 2021, and March 28, 2022, there were 395 unique responses to the survey. Overall, the respondents reported high satisfaction across all demographics, with a median rating of 8 out of 10 and 288/395 (47.6%) of the respondents giving a rating of 9 or 10 out of 10. User satisfaction scores were not associated with any demographic factors. The most common user-reported alternatives had the web-based tool not been available were calling the COVID-19 telephone hotline and sending a patient-portal message to their physician for advice. The ability to schedule a test online was the most important symptom checker feature for the respondents. The most common categories of user feedback were regarding other COVID-19 services (eg, telephone hotline), policies, or procedures, and requesting additional features or functionality. CONCLUSIONS: This analysis suggests that COVID-19 symptom checkers with self-triage and self-scheduling functionality may have high overall user satisfaction, regardless of user demographics. By allowing users to self-triage and self-schedule tests and visits, tools such as this may prevent unnecessary calls and messages to clinicians. Individual feedback suggested that the user experience for this type of tool is highly dependent on the organization's operational workflows for COVID-19 testing and care. This study provides insight for the implementation and improvement of COVID-19 symptom checkers to ensure high user satisfaction.
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While many case studies have described the implementation of self-scheduling tools, which allow patients to schedule visits and imaging studies asynchronously online, none have explored the impact of self-scheduling on equitable access to care.1 Using an electronic health record patient portal, University of California San Francisco deployed a self-scheduling tool that allowed patients to self-schedule diagnostic imaging studies. We analyzed electronic health record data for the imaging modalities with the option to be self-scheduled from January 1, 2021 to September 1, 2021. We used descriptive statistics to compare demographic characteristics and created a multivariable logistic regression model to identify predictors of patient self-scheduling utilization. Among all active patient portal users, Latinx, Black/African American, and non-English speaking patients were less likely to self-schedule studies. Patients with Medi-Cal, California's Medicaid program, and Medicare insurance were also less likely to self-schedule when compared with commercially insured patients. Efforts to facilitate use of patient portal-based applications are necessary to increase equitability and decrease disparities in access.
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Portales del Paciente , Anciano , Humanos , Estados Unidos , Medicare , Medicaid , Citas y Horarios , Diagnóstico por ImagenAsunto(s)
Toma de Decisiones , Motivación , Médicos , Calidad de la Atención de Salud , Reembolso de Incentivo , HumanosRESUMEN
The screening of healthcare workers for COVID-19 (coronavirus disease 2019) symptoms and exposures prior to every clinical shift is important for preventing nosocomial spread of infection but creates a major logistical challenge. To make the screening process simple and efficient, University of California, San Francisco Health designed and implemented a digital chatbot-based workflow. Within 1 week of forming a team, we conducted a product development sprint and deployed the digital screening process. In the first 2 months of use, over 270 000 digital screens have been conducted. This process has reduced wait times for employees entering our hospitals during shift changes, allowed for physical distancing at hospital entrances, prevented higher-risk individuals from coming to work, and provided our healthcare leaders with robust, real-time data for make staffing decisions.
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Betacoronavirus , Técnicas de Laboratorio Clínico/métodos , Infecciones por Coronavirus/diagnóstico , Personal de Salud , Aplicaciones Móviles , Neumonía Viral/diagnóstico , COVID-19 , Prueba de COVID-19 , Infecciones por Coronavirus/transmisión , Hospitales Universitarios , Humanos , Control de Infecciones/métodos , Transmisión de Enfermedad Infecciosa de Profesional a Paciente/prevención & control , Salud Laboral , Estudios de Casos Organizacionales , Pandemias/prevención & control , Neumonía Viral/transmisión , SARS-CoV-2 , San FranciscoRESUMEN
OBJECTIVE: To rapidly deploy a digital patient-facing self-triage and self-scheduling tool in a large academic health system to address the COVID-19 pandemic. MATERIALS AND METHODS: We created a patient portal-based COVID-19 self-triage and self-scheduling tool and made it available to all primary care patients at the University of California, San Francisco Health, a large academic health system. Asymptomatic patients were asked about exposure history and were then provided relevant information. Symptomatic patients were triaged into 1 of 4 categories-emergent, urgent, nonurgent, or self-care-and then connected with the appropriate level of care via direct scheduling or telephone hotline. RESULTS: This self-triage and self-scheduling tool was designed and implemented in under 2 weeks. During the first 16 days of use, it was completed 1129 times by 950 unique patients. Of completed sessions, 315 (28%) were by asymptomatic patients, and 814 (72%) were by symptomatic patients. Symptomatic patient triage dispositions were as follows: 193 emergent (24%), 193 urgent (24%), 99 nonurgent (12%), 329 self-care (40%). Sensitivity for detecting emergency-level care was 87.5% (95% CI 61.7-98.5%). DISCUSSION: This self-triage and self-scheduling tool has been widely used by patients and is being rapidly expanded to other populations and health systems. The tool has recommended emergency-level care with high sensitivity, and decreased triage time for patients with less severe illness. The data suggests it also prevents unnecessary triage messages, phone calls, and in-person visits. CONCLUSION: Patient self-triage tools integrated into electronic health record systems have the potential to greatly improve triage efficiency and prevent unnecessary visits during the COVID-19 pandemic.
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Citas y Horarios , Betacoronavirus , Infecciones por Coronavirus , Autoevaluación Diagnóstica , Sistemas de Registros Médicos Computarizados , Pandemias , Participación del Paciente , Portales del Paciente , Neumonía Viral , Triaje/métodos , Centros Médicos Académicos , Adulto , COVID-19 , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/epidemiología , Humanos , Neumonía Viral/diagnóstico , Neumonía Viral/epidemiología , SARS-CoV-2 , San Francisco , Autocuidado , Telemedicina/organización & administraciónAsunto(s)
Humanismo , Relaciones Médico-Paciente , Médicos/psicología , Humanos , Amor , Satisfacción PersonalRESUMEN
Hospitals are increasingly shifting toward value-based reimbursement and focusing on cost consciousness and patient experience. These concepts are crucial to high-quality, affordable healthcare. However, physicians are not well-trained in factoring cost and patient experience into clinical decisions. The addition of these ideas may create the opportunity for patient harm by depriving patients of necessary care. We discuss ways for physicians to mitigate this risk by engaging in online high value care curricula, using a "5-Question High Value Care Time Out," getting mentorship from master clinicians and using clinical decision support tools.