Inter-clinician eConsults without programmatic incentives or requirements: a qualitative study of primary care provider perspectives.

BACKGROUND: Inter-clinician electronic consultation (eConsult) programmes are becoming more widespread in the USA as health care systems seek innovative ways of improving specialty access. Existing studies examine models with programmatic incentives or requirements for primary care providers (PCPs) to participate. OBJECTIVE: We aimed to examine PCP perspectives on eConsults in a system with no programmatic incentive or requirement for PCPs to use eConsults. METHODS: We conducted seven focus groups with 41 PCPs at a safety-net community teaching health care system in Eastern Massachusetts, USA. RESULTS: Focus groups revealed that eConsults improved PCP experience by enabling patient-centred care and enhanced PCP education. However, increased workload and variations in communication patterns added challenges for PCPs. Patients were perceived as receiving timelier and more convenient care. Timelier care combined with direct documentation in the patient record was perceived as improving patient safety. Although cost implications were less clear, PCPs perceived costs as being lowered through fewer unnecessary visits and laboratories. CONCLUSIONS: Our findings suggest that eConsult systems with no programmatic incentives or requirements for PCPs have the potential to improve care.

Experiences applying for and understanding health insurance under Massachusetts health care reform.

BACKGROUND: The Affordable Care Act was modeled on the Massachusetts Health Reform of 2006, which reduced the number of uninsured largely through a Medicaid expansion and the provision of publicly subsidized insurance obtained through a Health Benefits Exchange. METHODS: We surveyed a convenience sample of 780 patients seeking care in a safety-net system who obtained Medicaid or publicly subsidized insurance after the Massachusetts reform, as well as a group of employed patients with private insurance. RESULTS: We found that although most patients with Medicaid or publicly subsidized exchange-based plans were able to obtain assistance with applying for and choosing an insurance plan, substantial proportions of respondents experienced difficulties with the application process and with understanding coverage and cost features of plans. CONCLUSIONS: Under the Affordable Care Act, efforts to simplify the application process and reduce the complexity of plans may be warranted, particularly for vulnerable patient populations cared for by the medical safety net.

Emergency Department Expansion Versus Patient Flow Improvement: Impact on Patient Experience of Care.

BACKGROUND: Most strategies used to help improve the patient experience of care and ease emergency department (ED) crowding and diversion require additional space and personnel resources, major process improvement interventions, or a combination of both. OBJECTIVES: To compare the impact of ED expansion vs. patient flow improvement and the establishment of a rapid assessment unit (RAU) on the patient experience of care in a medium-size safety net ED. METHODS: This paper describes a study of a single ED wherein the department first undertook a physical expansion (2006 Q2 to 2007 Q2) followed by a reorganization of patient flow and establishment of an RAU (2009 Q2) by the use of an interrupted time series analysis. RESULTS: In the time period after ED expansion, significant negative trends were observed: decreasing Press Ganey percentiles (-4.1 percentile per quarter), increasing door-to-provider time (+4.9 minutes per quarter), increasing duration of stay (+13.2 minutes per quarter), and increasing percent of patients leaving without being seen (+0.11 per quarter). After the RAU was established, significant immediate impacts were observed for door-to-provider time (-25.8 minutes) and total duration of stay (-66.8 minutes). The trends for these indicators further suggested the improvements continued to be significant over time. Furthermore, the negative trends for the Press Ganey outcomes observed after ED expansion were significantly reversed and in the positive direction after the RAU. CONCLUSIONS: Our results demonstrate that the impact of process improvement and rapid assessment implementation is far greater than the impact of renovation and facility expansion.

Perceived affordability of health insurance and medical financial burdens five years in to Massachusetts health reform.

INTRODUCTION: Under the Massachusetts health reform, low income residents (those with incomes below 150 % of the Federal Poverty Level [FPL]) were eligible for Medicaid and health insurance exchange-based plans with minimal cost-sharing and no premiums. Those with slightly higher incomes (150 %-300 % FPL) were eligible for exchange-based plans that required cost-sharing and premium payments. METHODS: We conducted face to face surveys in four languages with a convenience sample of 976 patients seeking care at three hospital emergency departments five years after Massachusetts reform. We compared perceived affordability of insurance, financial burden, and satisfaction among low cost sharing plan recipients (recipients of Medicaid and insurance exchange-based plans with minimal cost-sharing and no premiums), high cost sharing plan recipients (recipients of exchange-based plans that required cost-sharing and premium payments) and the commercially insured. RESULTS: We found that despite having higher incomes, higher cost-sharing plan recipients were less satisfied with their insurance plans and perceived more difficulty affording their insurance than those with low cost-sharing plans. Higher cost-sharing plan recipients also reported more difficulty affording medical and non-medical health care as well as insurance premiums than those with commercial insurance. In contrast, patients with low cost-sharing public plans reported higher plan satisfaction and less financial concern than the commercially insured. CONCLUSIONS: Policy makers with responsibility for the benefit design of public insurance available under health care reforms in the U.S. should calibrate cost-sharing to income level so as to minimize difficulty affording care and financial burdens.

Affordability of health care under publicly subsidized insurance after Massachusetts health care reform: a qualitative study of safety net patients.

INTRODUCTION: The Affordable Care Act (ACA) and the 2006 Massachusetts (MA) health reform law, on which the ACA was based, aimed to improve the affordability of care largely by expanding publicly sponsored insurances. Both laws also aimed to promote consumer understanding of how to acquire, maintain and use these public plans. A prior study found an association between the level of cost-sharing required in these plans and the affordability of care. Preparatory to a quantitative study we conducted this qualitative study that aimed to examine (1) whether cost sharing levels built into the public insurance types that formed the backbone of the MA health reform led to unaffordability of care and if so, (2) how insurances with higher cost sharing levels led to unaffordability of care in this context. METHODS: We interviewed 12 consumers obtaining the most commonly obtained insurances under MA health reform (Medicaid and Commonwealth Care) at a safety net hospital emergency department. We purposefully interviewed a stratified sample of higher and low cost sharing recipients. We used a combination of inductive and deductive codes to analyze the data according to degree of cost-sharing required by different insurance types. RESULTS: We found that higher cost sharing plans led to unaffordability of care, as evidenced by unmet medical needs, difficulty affording basic non-medical needs due to expenditures on medical care, and reliance on non-insurance resources to pay for care. Participants described two principal mechanisms by which higher cost sharing led to unaffordability of care: (1) cost sharing above what their incomes allowed and (2) poor understanding of how to effectively acquire, maintain and utilize insurance new public plans. CONCLUSIONS: Further efforts to investigate the relationship between perceived affordability of care and understanding of insurance for the insurance types obtained under MA health reform may be warranted. A potential focus for further work may be quantitative investigation of how the level of calibration of cost-sharing to income and understanding of insurances under the MA reform was associated with perceived affordability of care.

Health care system hazard vulnerability analysis: an assessment of all public hospitals in Abu Dhabi.

Hazard vulnerability analysis (HVA) is used to risk-stratify potential threats, measure the probability of those threats, and guide disaster preparedness. The primary objective of this project was to analyse the level of disaster preparedness in public hospitals in the Emirate of Abu Dhabi, utilising the HVA tool in collaboration with the Disaster Medicine Section at Harvard Medical School. The secondary objective was to review each facility's disaster plan and make recommendations based on the HVA findings. Based on the review, this article makes eight observations, including on the need for more accurate data; better hazard assessment capabilities; enhanced decontamination capacities; and the development of hospital-specific emergency management programmes, a hospital incident command system, and a centralised, dedicated regional disaster coordination centre. With this project, HVAs were conducted successfully for the first time in health care facilities in Abu Dhabi. This study thus serves as another successful example of multidisciplinary emergency preparedness processes.

The effect of an ambulance diversion ban on emergency department length of stay and ambulance turnaround time.

STUDY OBJECTIVE: Massachusetts became the first state in the nation to ban ambulance diversion in 2009. It was feared that the diversion ban would lead to increased emergency department (ED) crowding and ambulance turnaround time. We seek to characterize the effect of a statewide ambulance diversion ban on ED length of stay and ambulance turnaround time at Boston-area EDs. METHODS: We conducted a retrospective, pre-post observational analysis of 9 Boston-area hospital EDs before and after the ban. We used ED length of stay as a proxy for ED crowding. We compared hospitals individually and in aggregate to determine any changes in ED length of stay for admitted and discharged patients, ED volume, and turnaround time. RESULTS: No ED experienced an increase in ED length of stay for admitted or discharged patients or ambulance turnaround time despite an increase in volume for several EDs. There was an overall 3.6% increase in ED volume in our sample, a 10.4-minute decrease in length of stay for admitted patients, and a 2.2-minute decrease in turnaround time. When we compared high- and low-diverting EDs separately, neither saw an increase in length of stay, and both saw a decrease in turnaround time. CONCLUSION: After the first statewide ambulance diversion ban, there was no increase in ED length of stay or ambulance turnaround time at 9 Boston-area EDs. Several hospitals actually experienced improvements in these outcome measures. Our results suggest that the ban did not worsen ED crowding or ambulance availability at Boston-area hospitals.

Study design for the Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency Care (IMMEDIATE) Trial: A double-blind randomized controlled trial of intravenous glucose, insulin, and potassium for acute coronary syndromes in emergency medical services.

BACKGROUND: Experimental studies suggest that metabolic myocardial support by intravenous (IV) glucose, insulin, and potassium (GIK) reduces ischemia-induced arrhythmias, cardiac arrest, mortality, progression from unstable angina pectoris to acute myocardial infarction (AMI), and myocardial infarction size. However, trials of hospital administration of IV GIK to patients with ST-elevation myocardial infarction (STEMI) have generally not shown favorable effects possibly because of the GIK intervention taking place many hours after ischemic symptom onset. A trial of GIK used in the very first hours of ischemia has been needed, consistent with the timing of benefit seen in experimental studies. OBJECTIVE: The IMMEDIATE Trial tested whether, if given very early, GIK could have the impact seen in experimental studies. Accordingly, distinct from prior trials, IMMEDIATE tested the impact of GIK (1) in patients with acute coronary syndromes (ACS), rather than only AMI or STEMI, and (2) administered in prehospital emergency medical service settings, rather than later, in hospitals, after emergency department evaluation. DESIGN: The IMMEDIATE Trial was an emergency medical service-based randomized placebo-controlled clinical effectiveness trial conducted in 13 cities across the United States that enrolled 911 participants. Eligible were patients 30 years or older for whom a paramedic performed a 12-lead electrocardiogram to evaluate chest pain or other symptoms suggestive of ACS for whom electrocardiograph-based acute cardiac ischemia time-insensitive predictive instrument indicated a ≥75% probability of ACS, and/or the thrombolytic predictive instrument indicated the presence of a STEMI, or if local criteria for STEMI notification of receiving hospitals were met. Prehospital IV GIK or placebo was started immediately. Prespecified were the primary end point of progression of ACS to infarction and, as major secondary end points, the composite of cardiac arrest or in-hospital mortality, 30-day mortality, and the composite of cardiac arrest, 30-day mortality, or hospitalization for heart failure. Analyses were planned on an intent-to-treat basis, on a modified intent-to-treat group who were confirmed in emergency departments to have ACS, and for participants presenting with STEMI. CONCLUSION: The IMMEDIATE Trial tested whether GIK, when administered as early as possible in the course of ACS by paramedics using acute cardiac ischemia time-insensitive predictive instrument and thrombolytic predictive instrument decision support, would reduce progression to AMI, mortality, cardiac arrest, and heart failure. It also tested whether it would provide clinical and pathophysiologic information on GIK's biological mechanisms.

Reasons why patients remain uninsured after Massachusetts' health care reform: a survey of patients at a safety-net hospital.

BACKGROUND: Following the 2006 Massachusetts health care reform, an estimated 316,492 residents remain uninsured. However, there have been no published studies that examine why Massachusetts residents remain uninsured four years into health reform. OBJECTIVE: To describe the characteristics of uninsured patients seeking acute medical care in Massachusetts after implementation of health care reform and reasons for lacking insurance. DESIGN AND PARTICIPANTS: We performed an in-person survey of a convenience sample of patients visiting the emergency department of the state's second largest safety net hospital between July 25, 2009 and March 20, 2010. We interviewed 431 patients age 18-64, 189 of whom were uninsured. MAIN MEASURES: Demographic and clinical characteristics, employment and insurance history, reasons for lacking insurance and views of the state's new "individual mandate". KEY RESULTS: The uninsured were largely employed (65.9%), but only a quarter (25.1%) of the employed uninsured had access to employer-sponsored insurance. The majority qualified for subsidized insurance (85.7% earned ≤ 300% of the federal poverty level), yet many reported being unable to find affordable insurance (32.7%). Over a third (35.2%) were uninsured because they had lost insurance due predominantly to job loss or policy cancellation. For nearly half of the uninsured (48.6%), the individual mandate had motivated them to try to find insurance, but they were unable to find insurance they could afford. CONCLUSIONS: After full implementation of the Massachusetts health reform, those remaining without insurance are largely the working poor who do not have access to, or cannot afford, either employer sponsored insurance or state subsidized insurance.

Access to care after Massachusetts' health care reform: a safety net hospital patient survey.

BACKGROUND: Massachusetts' health care reform substantially decreased the percentage of uninsured residents. However, less is known about how reform affected access to care, especially according to insurance type. OBJECTIVE: To assess access to care in Massachusetts after implementation of health care reform, based on insurance status and type. DESIGN AND PARTICIPANTS: We surveyed a convenience sample of 431 patients presenting to the Emergency Department of Massachusetts' second largest safety net hospital between July 25, 2009 and March 20, 2010. MAIN MEASURES: Demographic and clinical characteristics, insurance coverage, measures of access to care and cost-related barriers to care. KEY RESULTS: Patients with Commonwealth Care and Medicaid, the two forms of insurance most often newly-acquired under the reform, reported similar or higher utilization of and access to outpatient visits and rates of having a usual source of care, compared with the privately insured. Compared with the privately insured, a significantly higher proportion of patients with Medicaid or Commonwealth Care Type 1 (minimal cost sharing) reported delaying or not getting dental care (42.2 % vs. 27.1 %) or medication (30.0 % vs. 7.0 %) due to cost; those with Medicaid also experienced cost-related barriers to seeing a specialist (14.6 % vs. 3.5 %) or getting recommended tests (15.6 % vs. 5.9 %). Those with Commonwealth Care Types 2 and 3 (greater cost sharing) reported significantly more cost-related barriers to obtaining care than the privately insured (45.0 % vs. 16.0 %), to seeing a primary care doctor (25.0 % vs. 6.0 %) or dental provider (58.3 % vs. 27.1 %), and to obtaining medication (20.8 % vs. 7.0 %). No differences in cost-related barriers to preventive care were found between the privately and publicly insured. CONCLUSIONS: Access to care improved less than access to insurance following Massachusetts' health care reform. Many newly insured residents obtained Medicaid or state subsidized private insurance; cost-related barriers to access were worse for these patients than for the privately insured.

Out-of-hospital administration of intravenous glucose-insulin-potassium in patients with suspected acute coronary syndromes: the IMMEDIATE randomized controlled trial.

CONTEXT: Laboratory studies suggest that in the setting of cardiac ischemia, immediate intravenous glucose-insulin-potassium (GIK) reduces ischemia-related arrhythmias and myocardial injury. Clinical trials have not consistently shown these benefits, possibly due to delayed administration. OBJECTIVE: To test out-of hospital emergency medical service (EMS) administration of GIK in the first hours of suspected acute coronary syndromes (ACS). DESIGN, SETTING, AND PARTICIPANTS: Randomized, placebo-controlled, double-blind effectiveness trial in 13 US cities (36 EMS agencies), from December 2006 through July 31, 2011, in which paramedics, aided by electrocardiograph (ECG)-based decision support, randomized 911 (871 enrolled) patients (mean age, 63.6 years; 71.0% men) with high probability of ACS. INTERVENTION: Intravenous GIK solution (n = 411) or identical-appearing 5% glucose placebo (n = 460) administered by paramedics in the out-of-hospital setting and continued for 12 hours. MAIN OUTCOME MEASURES: The prespecified primary end point was progression of ACS to myocardial infarction (MI) within 24 hours, as assessed by biomarkers and ECG evidence. Prespecified secondary end points included survival at 30 days and a composite of prehospital or in-hospital cardiac arrest or in-hospital mortality, analyzed by intent-to-treat and by presentation with ST-segment elevation. RESULTS: There was no significant difference in the rate of progression to MI among patients who received GIK (n = 200; 48.7%) vs those who received placebo (n = 242; 52.6%) (odds ratio [OR], 0.88; 95% CI, 0.66-1.13; P = .28). Thirty-day mortality was 4.4% with GIK vs 6.1% with placebo (hazard ratio [HR], 0.72; 95% CI, 0.40-1.29; P = .27). The composite of cardiac arrest or in-hospital mortality occurred in 4.4% with GIK vs 8.7% with placebo (OR, 0.48; 95% CI, 0.27-0.85; P = .01). Among patients with ST-segment elevation (163 with GIK and 194 with placebo), progression to MI was 85.3% with GIK vs 88.7% with placebo (OR, 0.74; 95% CI, 0.40-1.38; P = .34); 30-day mortality was 4.9% with GIK vs 7.7% with placebo (HR, 0.63; 95% CI, 0.27-1.49; P = .29). The composite outcome of cardiac arrest or in-hospital mortality was 6.1% with GIK vs 14.4% with placebo (OR, 0.39; 95% CI, 0.18-0.82; P = .01). Serious adverse events occurred in 6.8% (n = 28) with GIK vs 8.9% (n = 41) with placebo (P = .26). CONCLUSIONS: Among patients with suspected ACS, out-of-hospital administration of intravenous GIK, compared with glucose placebo, did not reduce progression to MI. Compared with placebo, GIK administration was not associated with improvement in 30-day survival but was associated with lower rates of the composite outcome of cardiac arrest or in-hospital mortality. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00091507.

Emergency department utilization after the implementation of Massachusetts health reform.

STUDY OBJECTIVE: Health care reform in Massachusetts improved access to health insurance, but the extent to which reform affected utilization of the emergency department (ED) for conditions potentially amenable to primary care is unclear. Our objective is to determine the relationship between health reform and ED use for low-severity conditions. METHODS: We studied ED visits, using a convenience sample of 11 Massachusetts hospitals for identical 9-month periods before and after health care reform legislation was implemented in 2006. Individuals most affected by the health reform law (the uninsured and low-income populations covered by the publicly subsidized insurance products) were compared with individuals unlikely to be affected by the legislation (those with Medicare or private insurance). Our main outcome measure was the rate of overall and low-severity ED visits for the study population and the comparison population during the period before and after health reform implementation. RESULTS: Total visits increased from 424,878 in 2006 to 442,102 in 2008. Low-severity visits among publicly subsidized or uninsured patients decreased from 43.8% to 41.2% of total visits for that group (difference=2.6%; 95% confidence interval [CI] 2.25% to 2.85%), whereas low-severity visits for privately insured and Medicare patients decreased from 35.7% to 34.9% of total visits for that group (difference=0.8%; 95% CI 0.62% to 0.98%), for a difference in differences of 1.8% (95% CI 1.7% to 1.9%). CONCLUSION: Although overall ED volume continues to increase, Massachusetts health reform was associated with a small but statistically significant decrease in the rate of low-severity visits for those populations most affected by health reform compared with a comparison population of individuals less likely to be affected by the reform. Our findings suggest that access to health insurance is only one of a multitude of factors affecting utilization of the ED.

Emergency medical service predictive instrument-aided diagnosis and treatment of acute coronary syndromes and ST-segment elevation myocardial infarction in the IMMEDIATE trial.

BACKGROUND: A challenge for emergency medical service (EMS) is accurate identification of acute coronary syndromes (ACS) and ST-segment elevation myocardial infarction (STEMI) for immediate treatment and transport. The electrocardiograph-based acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) and the thrombolytic predictive instrument (TPI) have been shown to improve diagnosis and treatment in emergency departments (EDs), but their use by paramedics in the community has been less studied. OBJECTIVE: To identify candidates for participation in the Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency Care (IMMEDIATE) Trial, we implemented EMS use of the ACI-TIPI and the TPI in out-of-hospital electrocardiographs and evaluated its impact on paramedic on-site identification of ACS and STEMI as a community-based approach to improving emergency cardiac care. METHODS: Ambulances in the study municipalities were outfitted with electrocardiographs with ACI-TIPI and TPI software. Using a before-after quasi-experimental design, in Phase 1, for seven months, paramedics were provided with the ACI-TIPI/TPI continuous 0-100% predictions automatically printed on electrocardiogram (ECG) text headers to supplement their identification of ACS; in Phase 2, for 11 months, paramedics were told to identify ACS based on an ACI-TIPI cutoff probability of ACS ≥ 75% and/or TPI detection of STEMI. In Phase 3, this cutoff approach was used in seven additional municipalities. Confirmed diagnoses of ACS, acute myocardial infarction (AMI), and STEMI were made by blinded physician review for 100% of patients. RESULTS: In Phase 1, paramedics identified 107 patients as having ACS; in Phase 2, 104. In Phase 1, 45.8% (49) of patients so identified had ACS confirmed, which increased to 76.0% (79) in Phase 2 (p < 0.001). Of those with ACS, 59.2% (29) had AMI in Phase 1 versus 84.8% (67) with AMI in Phase 2 (p < 0.01), and STEMI was confirmed in 40.8% (20) versus 68.4% (54), respectively (p < 0.01). In Phase 3, of 226 patients identified by paramedics as having ACS, 74.3% (168) had ACS confirmed, of whom 81.0% (136) had AMI and 65.5% (110) had STEMI. Among patients with ACS, the proportion who received percutaneous coronary intervention (PCI) was 30.6% (15) in Phase 1, increasing to 57.0% (45) in Phase 2 (p < 0.004) and 50.6% (85) in Phase 3, and the proportions of patients with STEMI receiving PCI rose from 75.0% (15) to 83.3% (45) (p < 0.4) and 82.7% (91). CONCLUSIONS: In a wide range of EMS systems, use of electrocardiographs with ACI-TIPI and TPI decision support using a 75% ACI-TIPI cutoff improves paramedic diagnostic performance for ACS, AMI, and STEMI and increases the proportions of patients who receive PCI.

Utilization of emergency medical services by patients with acute coronary syndromes in the Arab Gulf States.

BACKGROUND: Emergency Medical Services (EMS) play a central role in caring for patients with acute coronary syndromes (ACS). To date, no data exist on utilization of EMS systems in the Arab Gulf States. OBJECTIVE: To examine EMS use by patients with ACS in the Gulf Registry of Acute Coronary Events (Gulf RACE). METHODS: Gulf RACE was a prospective, multinational study conducted in 2007 of all patients hospitalized with ACS in 65 centers in six Arab countries. Data were analyzed based on mode of presentation (EMS vs. other). RESULTS: Of 7859 patients hospitalized with ACS through the emergency department (ED), only 1336 (17%) used EMS, with wide variation among countries (2% in Yemen to 37% in Oman). Younger age (odds ratio [OR] 1.09; 95% confidence interval [CI] 1.03-1.15 per 10-year decrement), presence of chest pain (OR 1.73; 95% CI 1.48-2.03), prior myocardial infarction (OR 1.58; 95% CI 1.34-1.86), prior percutaneous coronary intervention (OR 1.27; 95% CI 1.02-1.59), family history of premature coronary disease (OR 1.25; 95% CI 1.09-1.51), and current smoking (OR 1.30; 95% CI 1.13-1.50) were independently associated with not utilizing EMS. Patients with ST-segment elevation myocardial infarction/left bundle branch block myocardial infarction who were transported by EMS were significantly less likely to exhibit major delay in presentation, and were significantly more likely to receive favorable processes of care, including shorter door-to-electrocardiogram time, more frequent coronary reperfusion therapy, and thrombolytic therapy within 30 min of arrival at the ED. CONCLUSION: Despite current recommendations, fewer than 1 in 5 patients with ACS use EMS in the Arab Gulf States, highlighting a significant opportunity for improvement. Factors causing this underutilization deserve further investigation.

Trial to end ambulance diversion in Boston: report from the conference of the Boston teaching hospitals consortium.

INTRODUCTION: Annual ambulance diversion hours in Boston increased more than six-fold from 1997 to 2006. Although interventions and best practices were implemented, there was no reduction in the number of diversion hours. OBJECTIVES: A consortium of Boston teaching hospitals instituted a two-week moratorium on citywide diversion from 02 October 2006 to 15 October 2006. The hypothesis was that there would be no significant difference in measures of hospital and emergency medical services (EMS) efficiency compared with the two weeks immediately prior. METHODS: A total of nine hospitals and the municipal emergency medical services in Boston submitted data for analysis. The following mean daily hospital measures were studied: (1) emergency department volume; (2) number of emergency department admissions; (3) length of stay (LOS) for all patients; and (4) number of elopements. Mean EMS at-hospital time by destination and the percent of all Boston EMS transports to each hospital destination were calculated. The median differences (MD) were calculated as "before" minus "during" the study period and were compared with paired, Wilcoxon, non-parametric tests. Additional mean EMS measures for all destinations included: (1) to hospital time; (2) number of responses with transport initiated per day; (3) incident entry to arrival; and (4) at-hospital time. RESULTS: The LOS for admitted patients (MD = 0.30 hours; IQR 0.10,1.30; p = 0.03) and number of daily admissions (MD = -1.50 patients; IQR -1.50, -0.10; p = 0.04) were significantly different statistically. The results for LOS for all patients, LOS for discharged patients, ED volume, EMS time at hospital by destination, number of elopements, and percent of Boston EMS transports to each hospital revealed no statistically significant differences. The difference between the study and control periods for mean EMS to hospital time, at-hospital time, and incident entry to arrival was a maximum of 0.6 minutes. The vast majority of EMS respondents to an online survey believed that the "no diversion" policy should be made routine practice. CONCLUSIONS: The LOS for admitted patients decreased by 18 minutes, and the number of admissions increased by 1.5 patients per day during the study period. The "no diversion" policy resulted in minimal changes in EMS efficiency and operations. Diversion was temporarily eliminated in a major city without significant detrimental changes in ED, hospital, or EMS efficiency.

Do Medical Scribes Help Primary Care Providers Respond More Quickly to Out-of-Visit Tasks?

PURPOSE: Medical scribes are charged with decreasing documentation burden associated with patient visits. Reducing time spent on documentation may afford providers the opportunity to respond to out-of-visit inbox tasks faster. METHODS: We compare changes in the time taken to address patient portal messages, prescription requests, and test results from before to after scribe implementation among scribed primary care providers (PCPs), compared with nonscribed PCPs during the same time period. We used generalized estimating equations with robust standard errors to account for repeated measures and the hierarchical nature of the data, and adjusted for provider and patient characteristics. RESULTS: We examined 472,411 tasks, including 27,645 tasks for 5 scribed PCPs and 444,766 tasks of 74 nonscribed PCPs. In unadjusted analyses, we found no change in time to completion for prescription refill requests, results and patient portal messages; the change in time to completion from pre to post intervention among scribed PCPs was 1.02 times that of nonscribed providers (P = .585) for prescription refill requests, 1.06 times that of nonscribed providers (P = .516) for patient portal messages, and 1.02 times that of nonscribed providers (P = .787) for results. Adjustment for provider and patient characteristics did not change these findings. CONCLUSIONS: Our study suggests that scribes are not associated with improved time to completion of inbox messages for PCPs. While scribes seem to have many benefits, our study suggests they may not improve time to completion of out-of-visit tasks. Reducing the time to completion for these tasks likely requires other interventions targeted to achieve those outcomes.

The financial advantages of medical scribes extend beyond increased visits.

Employing medical scribes can boost revenue for a practice, the authors show, well beyond being an opportunity to expand patient volume.

SARS-CoV-2 antibody seroprevalence after the first wave among workers at a community healthcare system in the Greater Boston area.

SARS-CoV-2 antibody seroprevalence among health-care workers (HCW) can assess past exposure and possible immunity, which varies across different regions, populations and times. We investigated the seroprevalence among HCW in Massachusetts (a region suffering high COVID-19 mortality) at the end of first wave of the SARS-CoV-2 pandemic. All HCW at Cambridge Health Alliance were invited to participate in this cross-sectional survey in June 2020. Those who volunteered, consented and provided a blood sample were included. Dried blood specimens from finger-prick sampling collected either at home by each HCW or onsite by the study team were analyzed for anti-SARS-CoV-2 IgM and IgG to the virus' receptor binding domain, using an enzyme-linked immunosorbent assay. IgM and IgG antibody abundance were categorized based on the number of standard deviations above the cross-reacting levels found in existing, pre-pandemic blood samples previously obtained by the Ragon Institute and analyzed by the Broad Institute (Cambridge, MA). Seroprevalence estimates were made based on 'positive' IgM or IgG using 'low' (>6 SD), 'medium' (>4.5 SD), and 'high' prevalence cutoffs (>3 SD).A total of 433 out of 5,204 eligible HCWs consented and provided samples. Participating HCWs had a lower cumulative incidence (from the start of the pandemic up to the bloodspot collections) of SARS-CoV-2 RT-PCR positivity (1.85%) compared to non-participants (3.29%). The low, medium, and high seroprevalence estimates were 8.1%, 11.3%, and 14.5%, respectively. The weighted estimates based on past PCR positivity were 13.9%, 19.4%, and 24.9%, respectively, for the entire healthcare system population after accounting for participation bias.

Association Between Provider Engagement, Staff Engagement, and Culture of Safety.

As healthcare organizations seek to improve patient experience, quality, and safety, employee engagement and perceptions of patient safety (POPS) have increasingly become foci of attention. Yet, the relationship between these constructs is poorly understood. We examined the correlation between provider and staff engagement (collectively, "employee engagement"), and between employee engagement and POPS in ambulatory and hospital environments. We found significant correlations between staff engagement and POPS, and between provider engagement and POPS in ambulatory and hospital environments. We also found significant correlation between provider and staff engagement. Although all correlations were weak (correlation coefficients of 0.17-0.47), there were significant increases in POPS with increases in employee engagement (in both ambulatory and hospital environments) and increases in provider engagement with increases in staff engagement. These increases range from 4% to 11% for every 17% increase in staff engagement. These findings suggest that healthcare systems seeking to improve provider engagement, staff engagement, and POPS may find synergistic effects between these efforts in ambulatory and hospital settings.

The role of fibrinolytics in the prehospital treatment of ST-elevation myocardial infarction (STEMI).

The efficacy of fibrinolytics in the treatment of ST-elevation myocardial infarction is directly related to the time of administration, with the first 2 h after symptom onset seen as a critical period for greatest improvement in cardiovascular parameters and mortality. The American College of Cardiology/American Heart Association recommends a medical contact to treatment time of 30 min for fibrinolysis in patients with ST-elevation myocardial infarction. In selected patients, reperfusion goals may be expedited with prehospital administration of fibrinolytics. In clinical trials, prehospital fibrinolysis markedly reduced the time from symptom onset to treatment, allowed earlier ST-segment resolution, and reduced short- and long-term mortality compared with in-hospital treatment. Prehospital fibrinolysis has become more feasible with the introduction of prehospital 12-lead electrocardiography, improved skills of emergency medical services personnel, improved communication with the Emergency Department, and the advent of bolus fibrinolysis. Rapid and accurate administration of a fibrinolytic is vital for the success of prehospital fibrinolysis.