Effects of Maryland's global budget revenue model on emergency department utilization and revisits.

BACKGROUND: In 2014, Maryland (MD) implemented a "global budget revenue" (GBR) program that prospectively sets hospital budgets. This program introduced incentives for hospitals to tightly control volume and meet budget targets. We examine GBR's effects on emergency department (ED) visits, admissions, and returns. METHODS: We performed an interrupted time-series analysis with difference-in-differences comparisons using 2012 to 2015 Healthcare Cost Utilization and Project data from MD, New York (NY), and New Jersey (NJ). We examined GBR's effects on ED visits/1,000 population, admissions from the ED, and ED returns at 72 h and 9 days. We also examined rates of admission, intensive care unit (ICU) stay, and in-hospital mortality among returns. To evaluate racial/ethnic and payer outcome disparities among ED returns, we performed a triple differences analysis. RESULTS: ED visits decreased with GBR adoption in MD relative to NY and NJ, by five and six visits/1,000 population, respectively. ED admissions declined relative to NY and NJ, by 0.6% and 1.8%, respectively. There was also a post-GBR decline in ED returns by 0.7%. Admissions among returns declined by 2%, while ICU and in-hospital mortality among returns remained relatively stable. ED return outcomes varied by racial/ethnic and payer group. Non-Hispanic Whites and non-Hispanic Blacks experienced a similar decline in returns, while returns remained unchanged among Hispanics/Latinos, widening the disparity gap. Payer group disparities between privately insured and Medicare, Medicaid, and uninsured individuals improved, with the disparity reduction most pronounced among the uninsured. CONCLUSIONS: GBR adoption was associated with lower ED utilization and admissions. ED returns and admissions among returns also decreased, while mortality and ICU stays among returns remained stable, suggesting that GBR has not led to adverse patient outcomes from fewer admissions. However, changes in ED return disparities varied by subgroup, indicating that improvements in care transitions may be uneven across patient populations.

The active role of interpreters in medical discourse - An observational study in emergency medicine.

OBJECTIVE: To study communicative tasks executed and related strategies used by patients, health professionals, and medical interpreters. METHODS: English proficient and limited English proficient emergency department patients were observed. The content of patient-hospital staff communication was documented via pen and paper. Key themes and differences across interpreter types were established through qualitative analysis. Themes and differences across interpreter type were vetted and updated through member checking interviews. RESULTS: 6 English proficient and 9 limited English proficient patients were observed. Key themes in communicative tasks included: establishing, maintaining, updating, and repairing understanding and rapport. All tasks were observed with English proficient and limited English proficient patients. The difference with limited English proficient patients was that medical interpreters played an active role in completing communicative tasks. Telephone-based interpreters faced challenges in facilitating communicative tasks based on thematic comparisons with in-person interpreters, including issues hearing and lost information due to the lack of visual cues. CONCLUSIONS: Professional interpreters play an important role in communication between language discordant patients and health professionals that goes beyond verbatim translation. PRACTICAL IMPLICATIONS: Training for interpreters and health professionals, and the design of tools for facilitating language discordant communication, should consider the role of interpreters beyond verbatim translation.

Emergency department care coordination strategies and perceived impact under Maryland's hospital payment reforms.

BACKGROUND: Emergency department (ED) care coordination plays an important role in facilitating care transitions across settings. We studied ED care coordination processes and their perceived effectiveness in Maryland (MD) hospitals, which face strong incentives to reduce hospital-based care through global budgets. METHODS: We conducted a qualitative study using semi-structured interviews to examine ED care coordination processes and perceptions of effectiveness. Interviews were conducted from January through October 2019 across MD hospital-based EDs. Results were reviewed to assign analytic domains and identify emerging themes. Descriptive statistics of ED care coordination staffing and processes were also calculated. RESULTS: A total of 25 in-depth interviews across 18 different EDs were conducted with ED physician leadership (n = 14) and care coordination staff (CCS) (n = 11). Across all EDs, there was significant variation in the hours and types of CCS coverage and the number of initiatives implemented to improve care coordination. Participants perceived ED care coordination as effective in facilitating safer discharges and addressing social determinants of health; however, adequate access to outpatient providers was a significant barrier. The majority of ED physician leaders perceived MD's policy reform as having a mixed impact, with improved care transitions and overall patient care as benefits, but increased physician workloads and worsened ED throughput as negative effects. CONCLUSIONS: EDs have responded to the value-based care incentives of MD's global budgeting program with investments to enhance care coordination staffing and a variety of initiatives targeting specific patient populations. Although the observed care coordination initiatives were broadly perceived to produce positive results, MD's global budgeting policies were also perceived to produce barriers to optimizing ED care. Further research is needed to determine the association of the various strategies to improve ED care coordination with patient outcomes to inform practice leaders and policymakers on the efficacy of the various approaches.

Qualitative findings from a pilot stage implementation of a novel organizational learning tool toward operationalizing the Safety-II paradigm in health care.

'Safety-II' is a new approach to safety, which emphasizes learning proactively about how safety and efficacy are achieved in everyday frontline work. Previous research developed a new lesson-sharing tool designed based on the Safety-II approach: Resilience Engineering Tool to Improve Patient Safety (RETIPS). The tool comprises questions designed to elicit narratives of adaptations that have contributed to effectiveness in care delivery. The purpose of this study is to revise and validate the design of RETIPS. The tool was revised based on feedback of clinicians at a large multi-specialty hospital, resulting in a version customized for anesthesia residents, RETIPS-AnRes. RETIPS-AnRes was administered on a pilot-basis to anesthesia resident groups for a limited period of time. A review of the reports obtained shows a strong alignment of responses with the conceptual basis of the tool, i.e. learning about how things go well in everyday work. The exemplars include both, specific instances of successful patient care, as well as generic routines that contribute to safe and/or effective care delivery. These findings support RETIPS as a tool to operationalize the Safety-II paradigm in healthcare. Lessons and implications for implementation on a wider scale are discussed.

Observational study to understand interpreter service use in emergency medicine: why the key may lie outside of the initial provider assessment.

OBJECTIVE: To characterise the use of interpreter services and other strategies used to communicate with limited English proficient (LEP) patients throughout their emergency department visit. METHODS: We performed a process tracing study observing LEP patients throughout their stay in the emergency department. A single observer completed 47 hours of observation of 103 communication episodes between staff and nine patients with LEP documenting the strategy used to communicate (eg, professional interpreter, family member, own language skills) and duration of conversations for each communicative encounter with hospital staff members. Data collection occurred in a single emergency department in the eastern USA between July 2017 and February 2018. RESULTS: The most common strategy (per communicative encounter) was for the emergency department staff to communicate with the patient in English (observed in 29.1% of encounters). Total time spent in communicating was highest using telephone-based interpreters (32.9% of total time spent communicating) and in-person interpreters (29.2% of total time spent communicating). Communicative mechanism also varied by care task/phase of care with the most use of interpreter services or Spanish proficient staff (as primary communicator) occurring during triage (100%) and the initial provider assessment (100%) and the lowest interpreter service use during ongoing evaluation and treatment tasks (24.3%). CONCLUSIONS: Emergency department staff use various mechanisms to communicate with LEP patients throughout their length of stay. Utilisation of interpreter services was poorest during evaluation and treatment tasks, indicating that this area should be a focus for improving communication with LEP patients.

Usability in Health IT: Beyond Compliance to Meaningful Design and Assessment.

The relatively rapid transition from a paper-based system to a digital system in healthcare has not always employed a sophisticated integration of usability concepts. Yet usability is critical to safety and to effectiveness of the electronic health record, and regulators and policy makers have been increasingly focused on this area. This panel will provide a variety of perspectives on this important issue, ranging from a description of the problem based on current vendor usability practices; recommendations regarding domain content rich usability processes including use cases, assessments, and scenarios; and the extension of usability assessments and design improvements to post-system implementation.

Assessment of Innovative Emergency Department Information Displays in a Clinical Simulation Center.

The objective of this work was to assess the functional utility of new display concepts for an emergency department information system created using cognitive systems engineering methods, by comparing them to similar displays currently in use. The display concepts were compared to standard displays in a clinical simulation study during which nurse-physician teams performed simulated emergency department tasks. Questionnaires were used to assess the cognitive support provided by the displays, participants' level of situation awareness, and participants' workload during the simulated tasks. Participants rated the new displays significantly higher than the control displays in terms of cognitive support. There was no significant difference in workload scores between the display conditions. There was no main effect of display type on situation awareness, but there was a significant interaction; participants using the new displays showed improved situation awareness from the middle to the end of the session. This study demonstrates that cognitive systems engineering methods can be used to create innovative displays that better support emergency medicine tasks, without increasing workload, compared to more standard displays. These methods provide a means to develop emergency department information systems-and more broadly, health information technology-that better support the cognitive needs of healthcare providers.

The impact of interoperability of electronic health records on ambulatory physician practices: a discrete-event simulation study.

BACKGROUND: The effect of health information technology (HIT) on efficiency and workload among clinical and nonclinical staff has been debated, with conflicting evidence about whether electronic health records (EHRs) increase or decrease effort. None of this paper to date, however, examines the effect of interoperability quantitatively using discrete event simulation techniques. OBJECTIVE: To estimate the impact of EHR systems with various levels of interoperability on day-to-day tasks and operations of ambulatory physician offices. METHODS: Interviews and observations were used to collect workflow data from 12 adult primary and specialty practices. A discrete event simulation model was constructed to represent patient flows and clinical and administrative tasks of physicians and staff members. RESULTS: High levels of EHR interoperability were associated with reduced time spent by providers on four tasks: preparing lab reports, requesting lab orders, prescribing medications, and writing referrals. The implementation of an EHR was associated with less time spent by administrators but more time spent by physicians, compared with time spent at paper-based practices. In addition, the presence of EHRs and of interoperability did not significantly affect the time usage of registered nurses or the total visit time and waiting time of patients. CONCLUSION: This paper suggests that the impact of using HIT on clinical and nonclinical staff work efficiency varies, however, overall it appears to improve time efficiency more for administrators than for physicians and nurses.

Emergency medical service attitudes toward geriatric prehospital care and continuing medical education in geriatrics.

OBJECTIVES: To understand the opinions of emergency medical service (EMS) providers regarding their ability to care for older adults, the domains of geriatric medicine in which they need more training, and the modality through which continuing education could be best delivered. DESIGN: Qualitative study using key informant interviews. SETTING: Prehospital EMS system in Rochester, New York. PARTICIPANTS: EMS providers, EMS instructors and administrators, emergency physicians, and geriatricians. MEASUREMENTS: Semistructured interviews were conducted using an interview guide that addressed knowledge and skill deficiencies, recommendations for improvement of geriatrics continuing education, and delivery methods of education. RESULTS: Participant responses were generally congruous despite the diverse backgrounds, and redundancy was achieved rapidly. All participants perceived a deficit in EMS education on the care of older adults, particularly related to communications with patients and skilled nursing facility staff. All desired more geriatric continuing education for EMS providers, especially in communications and psychosocial issues. Education was desired in various modalities. CONCLUSION: Further geriatric continuing education for EMS providers is needed. Some specific topics relate to medical issues, but a large proportion involve communications and psychosocial issues. Education should be delivered in a variety of modalities to meet the needs of the EMS community. Emerging on-line video technologies may bridge the gap between learners preferring classroom-based modailities and those preferring self-study modules.

Tort claims and adverse events in emergency medical services.

STUDY OBJECTIVE: Emergency medical services (EMS) provide care to acutely ill or injured patients in settings less controlled than other health care environments. Although reports describing individual EMS adverse events exist, few broader descriptions exist. The objective of the study is to characterize the types, frequencies, and outcomes of adverse events associated with insurance tort claims against EMS providers. METHODS: We performed a retrospective review of insurance liability claims from a national insurer of EMS agencies. We studied closed and open insurance liability claims from January 1, 2003, to December 31, 2004, arising from EMS response to or provision of patient care and associated with injury to patients or other individuals. We excluded events associated with employee injuries only, events with property or vehicle damage only, and emergency vehicle crashes with less than $10,000 in actual or predicted total incurred costs. We identified the category of the adverse event, the characteristics of the treating emergency units, the injured individuals, the associated injuries, and the estimated or actual total incurred costs. RESULTS: Among 326 claims included in the analysis, adverse events included emergency vehicle crash or movement (n=122; 37%; 95% confidence interval [CI] 32% to 43%), patient handling (n=118; 36%; 95% CI 31% to 41%), clinical management (n=40; 12%; 95% CI 9% to 16%), response or transport events (n=25, 8%; 95% CI 5% to 11%), and other events (n=33; 10%; 95% CI 7% to 14%). Associated injuries included death (n=54; 17%; 95% CI 13% to 21%), life-threatening or disabling injuries (n=25; 8%, 95% CI 5% to 11%), and non-life-threatening or other injuries (n=247; 76%; 95% CI 71% to 80%). The median estimated total incurred cost was $17,000 (interquartile range $7,000 to $42,000). CONCLUSION: Emergency vehicle crashes and patient handling mishaps were the most common adverse events associated with tort claims against EMS agencies. Clinical management and other incidents were less common. This effort highlights potential areas for improving EMS operations and care.

Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events.

BACKGROUND: Patients in intensive care units (ICUs) frequently experience adverse drug events involving intravenous medications (IV-ADEs), which are often preventable. OBJECTIVES: To determine how frequently preventable IV-ADEs in ICUs match the safety features of a programmable infusion pump with safety software ("smart pump") and to suggest potential improvements in smart-pump design. DESIGN: Using retrospective medical-record review, we examined preventable IV-ADEs in ICUs before and after 2 hospitals replaced conventional pumps with smart pumps. The smart pumps alerted users when programmed to deliver duplicate infusions or continuous-infusion doses outside hospital-defined ranges. PARTICIPANTS: 4,604 critically ill adults at 1 academic and 1 nonacademic hospital. MEASUREMENTS: Preventable IV-ADEs matching smart-pump features and errors involved in preventable IV-ADEs. RESULTS: Of 100 preventable IV-ADEs identified, 4 involved errors matching smart-pump features. Two occurred before and 2 after smart-pump implementation. Overall, 29% of preventable IV-ADEs involved overdoses; 37%, failures to monitor for potential problems; and 45%, failures to intervene when problems appeared. Error descriptions suggested that expanding smart pumps' capabilities might enable them to prevent more IV-ADEs. CONCLUSION: The smart pumps we evaluated are unlikely to reduce preventable IV-ADEs in ICUs because they address only 4% of them. Expanding smart-pump capabilities might prevent more IV-ADEs.

Costs of intravenous adverse drug events in academic and nonacademic intensive care units.

BACKGROUND: Adverse drug events (ADEs), particularly those involving intravenous medications (IV-ADEs), are common among intensive care unit (ICU) patients and may increase hospitalization costs. Precise cost estimates have not been reported for academic ICUs, and no studies have included nonacademic ICUs. OBJECTIVES: To estimate increases in costs and length of stay after IV-ADEs at an academic and a nonacademic hospital. RESEARCH DESIGN: This study reviewed medical records to identify IV-ADEs, and then, using a nested case-control design with propensity-score matching, assessed differences in costs and length of stay between cases and controls. SUBJECTS: : A total of 4604 adult ICU patients in 3 ICUs at an academic hospital and 2 ICUs at a nonacademic hospital in 2003 and 2004. MEASURES: Increased cost and length of stay associated with IV-ADEs. RESULTS: : Three hundred ninety-seven IV-ADEs were identified: 79% temporary physical injuries, 0% permanent physical injuries, 20% interventions to sustain life, and 2% in-hospital deaths. In the academic ICUs, patients with IV-ADEs had $6647 greater costs (P < 0.0001) and 4.8-day longer stays (P = 0.0003) compared with controls. In the nonacademic ICUs, IV-ADEs were not associated with greater costs ($188, P = 0.4236) or lengths of stay (-0.3 days, P = 0.8016). Cost and length-of-stay differences between the hospitals were statistically significant (P = 0.0012). However, there were no differences in IV-ADE severity or preventability, and the characteristics of patients experiencing IV-ADEs differed only modestly. CONCLUSIONS: IV-ADEs substantially increased hospitalization costs and length of stay in ICUs at an academic hospital but not at a nonacademic hospital, likely because of differences in practices after IV-ADEs occurred.

Usability study of two common defibrillators reveals hazards.

STUDY OBJECTIVE: This usability study evaluates the user interface of 2 common monitor-defibrillators, the Lifepak10 and Lifepak12, to identify use-related hazards. METHODS: Fourteen paramedics familiar with both devices completed 4 EMS simulator scenarios using each device. The scenarios involved "quick look" and monitoring, defibrillation, synchronized cardioversion, and replacing paper. Qualitative and quantitative data were collected, including both participant self-evaluation (scored 1 to 9) and expert observer evaluation (scored 0 to 4). RESULTS: Participant ratings demonstrated that for performing a quick look, the Lifepak10 was easier to use (mean 8.0 versus 7.1), and for synchronized cardioversion the Lifepak12 was easier (mean 6.7 versus 5.3). Participants performed better on the Lifepak12 than the Lifepak10 for synchronized cardioversion (mean 3.1 versus 1.6) and replacing paper (mean 3.0 versus 2.1). One participant did not complete the final questionnaire. Of the remaining 13, 11 (85%) participants preferred the Lifepak12 for use on a regular basis. Eight (62%) paramedics thought that the Lifepak12 would be more effective in an emergency; 9 (69%) believed that the Lifepak10 is quicker to learn. Paramedics reported difficulty using the devices with gloves and confusion in "sync" mode. Of note, 50% of participants inadvertently delivered an unsynchronized countershock for supraventricular tachycardia. CONCLUSION: Although the Lifepak10 is easier to learn, the Lifepak12 is perceived as easier to use and more effective in emergencies. The high failure rate in synchronized cardioversion indicates a need to reevaluate the user interface design for this function. Limitations of this study include the use of simulation.

Care without coverage: is there a relationship between insurance and ED care?

The Institute of Medicine (IOM) has concluded that differences in care exist for hospitalized patients on the basis of insurance; we attempted to determine if these differences begin in the emergency department (ED). We retrospectively studied high-acuity adult visits to one ED over 6 months, utilizing electronic databases. Uninsured patients were more often younger, male, and non-white (n = 3899 visits; 468 uninsured, 3431 insured). Fewer uninsured patients were admitted (9.8% vs. 27.2% insured; p < 0.001). Comparing patients by admission status, there was no evidence of difference for most measures, excepting radiographic studies (admitted patients: 78.3% uninsured vs. 90.5% insured, p = 0.007; treated-and-released patients: 62.3% uninsured vs. 69.4% insured, p = 0.004). In a subset of trauma patients for whom acuity could be evaluated with Injury Severity Scores (ISS), admission rates were similar. In this pilot study of high-acuity patients, there was limited evidence of differences in most measures of ED-based patient care on the basis of insurance status.