Bed downtime: the novel use of a quality metric allows inpatient providers to improve patient flow from the emergency department.

BACKGROUND: Emergency department (ED) boarding time is associated with increased length of stay (LOS) and inpatient mortality. Despite the documented impact of ED boarding on inpatient outcomes, a disparity continues to exist between the attention paid to the issue by inpatient and ED providers. A perceived lack of high yield strategies to address ED boarding from the perspective of the inpatient provider may discourage involvement in improvement initiatives on the subject. As such, further work is needed to identify inpatient metrics and strategies to address patient flow problems, and which may improve ED boarding time. METHODS: After initial system analysis, our multidisciplinary quality improvement (QI) group defined the process time metric 'bed downtime'-the time from which a bed is vacated by a discharged patient to the time an ED patient is assigned to that bed. Using the Lean Sigma QI approach, this metric was targeted for improvement on the internal medicine hospitalist service at a tertiary care academic medical centre. INTERVENTIONS: Interventions included improving inpatient provider awareness of the problem, real-time provider notification of empty beds, a weekly retrospective emailed performance dashboard and the creation of a guideline document for admission procedures. RESULTS: This package of interventions was associated with a 125 min reduction in mean bed downtime for incoming ED patients (254 min to 129 min) admitted to the intervention unit. CONCLUSION: Use of the bed downtime metric as a QI target was associated with marked improvements in process time during our project. The use of this metric may enhance the ability of inpatient providers to participate in QI efforts to improve patient flow from the ED. Further study is needed to determine if use of the metric may be effective at reducing boarding time without requiring alterations to LOS or discharge patterns.

Remote patient monitoring for ED discharges in the COVID-19 pandemic.

COVID-19 has had a significant effect on healthcare resources worldwide, with our knowledge of the natural progression of the disease evolving for the individual patient. To allow for early detection of worsening clinical status, protect hospital capacity and provide extended access for vulnerable patients, our emergency department developed a remote patient monitoring programme for discharged patients with COVID-19. The programme uses a daily emailed secure link to a survey in which patients submit biometric and symptoms data for monitoring. Patients' meeting criteria are escalated to a physician for a phone or video visit. Here, we describe the development, implementation and preliminary analysis of utilisation of the programme.

Emergency Department Ergonomic Redesign Improves Team Satisfaction in Cardiopulmonary Resuscitation Delivery: A Simulation-Based Quality Improvement Approach.

BACKGROUND: Delivering high-quality cardiopulmonary resuscitation (CPR) requires teams to administer highly choreographed care. The American Heart Association recommends audiovisual feedback for real-time optimization of CPR performance. In our Emergency Department (ED) resuscitation bays, ZOLL cardiac resuscitation device visibility was limited. OBJECTIVE: To optimize the physical layout of our resuscitation rooms to improve cardiac resuscitation device visibility for real-time CPR feedback. METHODS: A simulated case of cardiac arrest with iterative ergonomic modifications was performed four times. Variables included the locations of the cardiac resuscitation device and of team members. Participants completed individual surveys and provided qualitative comments in a group debriefing. The primary outcome of interest was participants' perception of cardiac resuscitation device visibility. RESULTS: The highest scoring layout placed the cardiac resuscitation device directly across from the compressor and mirrored the device screen to a television mounted at the head of the bed. Comparing this configuration to our standard configuration on a five-point Likert scale, cardiac resuscitation device visibility increased 46.7% for all team members, 150% for the team leader, and 179% for team members performing chest compressions. CONCLUSION: An iterative, multidisciplinary, simulation-based approach can improve team satisfaction with important clinical care factors when caring for patients suffering cardiac arrest in the ED.

Use of Systems Engineering to Design a Hospital Command Center.

BACKGROUND: In hospitals and health systems across the country, patient flow bottlenecks delay care delivery-emergency department boarding and operating room exit holds are familiar examples. In other industries, such as oil, gas, and air traffic control, command centers proactively manage flow through complex systems. METHODS: A systems engineering approach was used to analyze and maximize existing capacity in one health system, which led to the creation of the Judy Reitz Capacity Command Center. This article describes the key elements of this novel health system command center, which include strategic colocation of teams, automated visual displays of real-time data providing a global view, predictive analytics, standard work and rules-based protocols, and a clear chain of command and guiding tenets. Preliminary data are also shared. RESULTS: With proactive capacity management, subcycle times decreased and allowed the health system's flagship hospital to increase occupancy from 85% to 92% while decreasing patient delays. CONCLUSION: The command center was built with three primary goals-reducing emergency department boarding, eliminating operating room holds, and facilitating transfers in from outside facilities-but the command center infrastructure has the potential to improve hospital operations in many other areas.

An Electronic Dashboard to Monitor Patient Flow at the Johns Hopkins Hospital: Communication of Key Performance Indicators Using the Donabedian Model.

Efforts to monitoring and managing hospital capacity depend on the ability to extract relevant time-stamped data from electronic medical records and other information technologies. However, the various characterizations of patient flow, cohort decisions, sub-processes, and the diverse stakeholders requiring data visibility create further overlying complexity. We use the Donabedian model to prioritize patient flow metrics and build an electronic dashboard for enabling communication. Ten metrics were identified as key indicators including outcome (length of stay, 30-day readmission, operating room exit delays, capacity-related diversions), process (timely inpatient unit discharge, emergency department disposition), and structural metrics (occupancy, discharge volume, boarding, bed assignation duration). Dashboard users provided real-life examples of how the tool is assisting capacity improvement efforts, and user traffic data revealed an uptrend in dashboard utilization from May to October 2017 (26 to 148 views per month, respectively). Our main contributions are twofold. The former being the results and methods for selecting key performance indicators for a unit, department, and across the entire hospital (i.e., separating signal from noise). The latter being an electronic dashboard deployed and used at The Johns Hopkins Hospital to visualize these ten metrics and communicate systematically to hospital stakeholders. Integration of diverse information technology may create further opportunities for improved hospital capacity.

Bedside sonography for the diagnosis of esophageal food impaction.

BACKGROUND: Esophageal foreign body (EFB) and impaction are common gastrointestinal emergencies. Detection with standard imaging can be challenging. Computed tomography is a commonly used non-invasive imaging modality, but is not 100% sensitive and not always feasible. Sensitivity of plain film x-ray varies widely and the addition of a barium swallow can obscure evaluation by subsequent esophagogastroduodenoscopy (EGD). Use of emergency ultrasound (EUS) for detection of EFB in adults has not been previously studied. OBJECTIVE: To evaluate the role of EUS in detection of EFB and to characterize sonographic findings. METHODS: A case control series of five patients with clinical suspicion of EFB underwent EUS, and findings were compared to five healthy controls. Patients were evaluated for persistent air-fluid levels after swallowing, esophageal dilatation, and visualization of EFB. RESULTS: All patients with suspected EFB had esophageal dilatation (17.5mm vs 9.3mm in healthy controls; p=0.0011) and persistent air-fluid levels after swallowing. EFB was visualized on EUS in 60% of patients. All patients had EFB confirmed on EGD except one, who vomited a significant food bolus during EUS and prior to EGD. CONCLUSION: In patients with suspected EFB, point-of-care ultrasound may identify those with impaction. Suggestive findings include cervical esophageal dilatation and persistent intraluminal air-fluid levels after swallowing. EUS is a rapid, convenient test with the potential to expedite definitive management while decreasing cost and radiation exposure in this patient population.

Teaching medical students about obesity: a pilot program to address an unmet need through longitudinal relationships with bariatric surgery patients.

BACKGROUND: Despite obesity's relevance and impact, curricula addressing obesity are underrepresented in clinical medical education. A novel pilot program to begin teaching medical students about care of the obese patient was developed and student attitudes toward obesity and bariatric surgery were assessed. METHODS: The authors paired third-year students with obese patients undergoing bariatric surgery. Students established a longitudinal patient relationship, received faculty mentorship, and kept a reflections journal. An attitude assessment survey was administered before and after third year. Reflections were analyzed for common themes. RESULTS: Baseline student responses differed from those previously reported for practicing physicians on many survey statements, including more strongly agreeing with the relationship between obesity and serious medical conditions (P < .001), the need to educate patients about obesity risks (P < .001), and willingness to recommend bariatric surgery evaluation (P = .004). These differences were maintained after clinical clerkships. Reflection themes included recognition of obesity stereotypes, improved estimation of body mass index, and awareness of physicians' attitudes about obesity. CONCLUSION: Development and assessment of a novel pilot program to teach third-year medical students about obesity and bariatric surgery suggests a potential impact on student attitudes and understanding of obesity and obesity surgery. Students today may have different attitudes toward obesity than those reflected in prior data for physicians in practice, and programs such as this may help maintain positive attitudes.

Characterization of VP6 genes from rotavirus strains collected in the United States from 1996-2002.

We sequenced 22 VP6 genes from common rotavirus strains P[8], G1; P[4], G2; P[8], G3; P[8], G4 and P[8], G9 and uncommon type P[6], G9 collected in the US over a 6-year period. All strains defined as members of VP6 antigenic subgroup (SG) I according to reactivity patterns with monoclonal antibodies formed a genetic cluster (Genogroup I) with SG I reference strains. Similarly, all strains in antigenic SGII formed a group (Genogroup II) with corresponding standard strains of the same SG. Most US strains of each genogroup had diverged by 10-15% from the VP6 gene sequence of reference strains collected >20 years earlier and some recent isolates from other countries. Evolutionary analysis demonstrated that recently isolated US strains of both genogroups have diverged into 2-3 related clusters consistent with other recent findings. Unexpectedly, some recent isolates from other countries have diverged greatly from both older reference isolates and from the recent US isolates characterized here. This finding suggests that genetic diversity in human rotavirus VP6 genes may be greater than previously recognized. These sequences will help in the construction of a VP6 gene database to aid in the development of broadly reactive molecular assays and permit identification of regions where primers and probes for existing assays may need to be redesigned.

Role of AMP-activated protein kinase in exercise capacity, whole body glucose homeostasis, and glucose transport in skeletal muscle -insight from analysis of a transgenic mouse model-.

To examine the role of muscle AMP-activated protein kinase (AMPK) in maximal exercise capacity, whole body glucose homeostasis, and glucose transport in skeletal muscle, we generated muscle-specific transgenic mice carrying cDNAs of inactive AMPK alpha2 (alpha2i TG). Fed blood glucose was slightly higher in alpha2i TG mice compared to wild type littermates, however, the difference was not statistically significant. In alpha2i TG mice, glucose tolerance was slightly impaired in male, but not in female mice, compared to wild type littermates. Maximal exercise capacity was dramatically reduced in alpha2i TG mice, suggesting that AMPK alpha2 has a critical role in skeletal muscle during exercise. We confirmed that known insulin-independent stimuli of glucose transport including mitochondrial respiration inhibition, hyperosmolarity, and muscle contraction increased both AMPK alpha1 and alpha2 activities in isolated EDL muscle in wild type mice. While, alpha2 activation was severely blunted and alpha1 activation was only slightly reduced in alpha2i TG mice by these insulin independent stimuli compared to wild type mice. Mitochondrial respiration inhibition-induced glucose transport was fully inhibited in isolated EDL muscles in alpha2i TG mice. However, contraction- or hyperosmolarity-induced glucose transport was nearly normal. These results suggest that AMPK alpha2 activation is essential for some, but not all insulin-independent glucose transport.

AMP-activated protein kinase alpha2 activity is not essential for contraction- and hyperosmolarity-induced glucose transport in skeletal muscle.

To examine the role of AMP-activated protein kinase (AMPK) in muscle glucose transport, we generated muscle-specific transgenic mice (TG) carrying cDNAs of inactive alpha2 (alpha2i TG) and alpha1 (alpha1i TG) catalytic subunits. Extensor digitorum longus (EDL) muscles from wild type and TG mice were isolated and subjected to a series of in vitro incubation experiments. In alpha2i TG mice basal alpha2 activity was barely detectable, whereas basal alpha1 activity was only partially reduced. Known AMPK stimuli including 5-aminoimidazole-4-carboxamide-1-beta-4-ribofuranoside (AICAR), rotenone (a Complex I inhibitor), dinitrophenol (a mitochondrial uncoupler), muscle contraction, and sorbitol (producing hyperosmolar shock) did not increase AMPK alpha2 activity in alpha2i TG mice, whereas alpha1 activation was attenuated by only 30-50%. Glucose transport was measured in vitro using isolated EDL muscles from alpha2i TG mice. AICAR- and rotenone-stimulated glucose transport was fully inhibited in alpha2i TG mice; however, the lack of AMPK alpha2 activity had no effect on contraction- or sorbitol-induced glucose transport. Similar to these observations in vitro, contraction-stimulated glucose transport, assessed in vivo by 2-deoxy-d-[(3)H]glucose incorporation into EDL, tibialis anterior, and gastrocnemius muscles, was normal in alpha2i TG mice. Thus, AMPK alpha2 activation is essential for some, but not all, insulin-independent glucose transport. Muscle contraction- and hyperosmolarity-induced glucose transport may be regulated by a redundant mechanism in which AMPK alpha2 is one of multiple signaling pathways.

The epidemiology of rotavirus diarrhea in Latin America: anticipating rotavirus vaccines

OBJETIVO: Valorar la carga de enfermedad e identificar las características epidemiológicas de la diarrea causada por rotavirus en América Latina. MÉTODOS: Realizamos una revisión de la literatura que abarcaba los estudios de niños menores de 5 años que fueron hospitalizados o atendidos como pacientes ambulatorios a causa de la diarrea, y en los cuales se buscó al rotavirus como agente etiológico de la diarrea. Nuestro trabajo de revisión incluye los estudios publicados desde el año 1998 sobre pacientes ingresados y ambulatorios, que incluyeron a 100 niños o más, y que informaron sobre actividades de vigilancia que se prolongaron durante al menos 12 meses consecutivos. RESULTADOS: Un total de 18 estudios de pacientes ingresados y 10 estudios de pacientes ambulatorios satisficieron los criterios de inclusión de nuestro trabajo de revisión. Se detectó el rotavirus en el 31% (mediano) de los pacientes ingresados (intervalo del 16% al 52%) y en el 30.5% de los pacientes ambulatorios (intervalo del 4% al 42%). La tasa mediana de detección fue mayor en los estudios que emplearon un ensayo de encimoinmunoanálisis (ELISA) (pacientes ingresados: 38%, pacientes ambulatorios: 33%) frente a otros métodos de detección menos sensibles. La distribución de la enfermedad rotavírica según la edad difería entre países, aunque la proporción de niños hospitalizados durante el primer año de vida fue del 65% al 85%. En la mayoría de los países se produjeron ingresos hospitalarios por rotavirus durante todo el año, y el rotavirus normalmente mostraba un máximo estacional en el invierno tanto en las zonas de clima tropical como en aquellas de clima templado. CONCLUSIONES: La importante carga de enfermedad que se atribuye al rotavirus en América Latina sugiere que las vacunas que están siendo ensayadas en la actualidad podrían tener un impacto considerable en la prevención de las hospitalizaciones, consultas a los centros de salud, y muertes. La distribución de la enfermedad entre los pacientes más jóvenes subraya la importancia de la inmunización precoz en el éxito de los programas de vacunación. Los datos sugieren que en el futuro, los programas de vigilancia para detectar la diarrea causada por rotavirus en América Latina deberían usar un protocolo normalizado de vigilancia con ELISA para la detección del virus. Los datos provenientes de estudios de vigilancia serán de importancia fundamental para el seguimiento del impacto de la introducción de vacunas en el futuro.

Evaluation and comparison of two commercial enzyme-linked immunosorbent assay kits for detection of antigenically diverse human noroviruses in stool samples.

Two recently commercialized enzyme-linked immunosorbent assay kits, the SRSV(II)-AD (Denka Seiken Co. Ltd., Tokyo, Japan) and IDEIA NLV (DakoCytomation Ltd., Ely, United Kingdom) kits, that detect human norovirus (HuNV) antigens in stool samples were evaluated to assess whether they could be used instead of reverse transcription-PCR (RT-PCR) for routine diagnosis. The sensitivities and specificities of the two kits were tested with a panel of 103 stool samples containing HuNVs of 4 and 10 genetic subgroups within genogroups I and II (GI and GII), respectively, and 39 stool samples containing other enteric viruses. The Denka kit had a high sensitivity (>70% for 10 of the 14 subgroups) but a specificity of only 69%, and the Dako kit had a low sensitivity (<30% for 6 GII subgroups) but a high specificity of 100%. Statistical analysis suggests that HuNVs of four subgroups (subgroups GII/2, GII/5, GII/6, and GII/n) are likely to elude detection by the Dako kit. The two kits also demonstrated differences in reactivities. While the Dako kit discriminated between the GI and GII antigens of HuNVs, the Denka kit cross-reacted with samples containing all GI and GII subgroups of HuNVs. Moreover, the Denka kit also reacted with samples containing human sapovirus (HuSV). We demonstrate that the cross-reactivity of the Denka kit is not due to specific reactions with HuNV and HuSV antigens. These results indicate that neither the Denka kit nor the Dako kit has all the performance characteristics required to replace the RT-PCR methods used to detect HuNVs.

The epidemiology of rotavirus diarrhea in Latin America. Anticipating rotavirus vaccines.

OBJECTIVE: To assess the disease burden and characterize the epidemiology of rotavirus diarrhea in Latin America. METHODS: We conducted a literature review of studies of children < 5 years of age who were hospitalized or seen as outpatients for diarrhea and for whom rotavirus was sought as the etiologic agent of the diarrhea. This review included inpatient and outpatient studies published since 1998 that included at least 100 children and reported surveillance activities lasting at least 12 consecutive months. RESULTS: A total of 18 inpatient and 10 outpatient studies met the criteria for inclusion in this review. Rotavirus was detected in a median of 31% of inpatients (range, 16%-52%) and 30.5% of outpatients (range, 4%-42%). The median detection rate was higher in studies that used an enzyme-linked immunosorbent assay (ELISA) (inpatients 38%, outpatients 33%) versus less sensitive methods of detection. The age distribution of rotavirus disease varied among countries, with 65%-85% of children hospitalized in the first year of life. Most countries had rotavirus admissions year round, and rotavirus generally exhibited a winter seasonal peak in both temperate and tropical climates. CONCLUSIONS: The heavy burden of disease attributable to rotavirus in Latin America suggests that vaccines currently being tested could have considerable impact in preventing hospitalizations, clinic visits, and deaths. The findings of the young age distribution of patients highlight the importance of early immunization for the success of a vaccine program. The data suggest that future surveillance for rotavirus diarrhea in Latin America should use a standardized surveillance protocol with an ELISA for detection. Data from surveillance studies will be critical to monitor the impact of the future introduction of vaccines.