Meritus Health: Driving Data-Informed Decision-Making at Every Level.

With so much data available, health system leaders are challenged with sifting through it all to find the most useful information for decision-making. Meritus Health implemented effective approaches to understand, use, and communicate large amounts of data to alleviate some of this burden. These processes include system-wide daily huddles, dashboards, and standardized communication write-ups.

Effect of gabapentin on length of stay, opioid use, and pain scores in posterior spinal fusion for adolescent idiopathic scoliosis: a retrospective review across a multi-hospital system.

BACKGROUND: Gabapentin has been adopted in Enhanced Recovery After Surgery protocols as a means to reduce opioid consumption while maintaining adequate post-operative analgesia. The purpose of our study was to review and compare changes in length of stay, opioid use, and patient reported pain scores after the addition of gabapentin into five, distinct pain protocols for posterior spinal fusion in adolescent idiopathic scoliosis. METHODS: A retrospective review was completed using a database of electronic medical data from a single pediatric orthopedic healthcare system that was queried for patients with adolescent idiopathic scoliosis who underwent first-time posterior spinal fusion. Perioperative data including demographics, hospital length of stay, surgical details, opioid use, patient reported pain scores, and non-opioid analgesic use were collected. RESULTS: From December 2012 to February 2019, 682 hospitalizations for posterior spinal fusion in adolescent idiopathic scoliosis were identified with complete inpatient data; 49% were administered gabapentin. For the gabapentin cohort, the system saw no statistically significant effect on length of stay or pain averaged over POD#0-3. Opioid use was statistically lower averaged over POD#0-3. Individual sites saw variation on length of stay and opioid use compared to the system. CONCLUSION: In conclusion, system-wide data showed gabapentin containing protocols reduced opioid use while maintaining clinically equivalent analgesia. However, variations of individual site results make it difficult to conclude the degree to which gabapentin were responsible for this effect.

Quality assurance of integrative big data for medical research within a multihospital system.

BACKGROUND: The need is growing to create medical big data based on the electronic health records collected from different hospitals. Errors for sure occur and how to correct them should be explored. METHODS: Electronic health records of 9,197,817 patients and 53,081,148 visits, totaling about 500 million records for 2006-2016, were transmitted from eight hospitals into an integrated database. We randomly selected 10% of patients, accumulated the primary keys for their tabulated data, and compared the key numbers in the transmitted data with those of the raw data. Errors were identified based on statistical testing and clinical reasoning. RESULTS: Data were recorded in 1573 tables. Among these, 58 (3.7%) had different key numbers, with the maximum of 16.34/1000. Statistical differences (P < 0.05) were found in 34 (58.6%), of which 15 were caused by changes in diagnostic codes, wrong accounts, or modified orders. For the rest, the differences were related to accumulation of hospital visits over time. In the remaining 24 tables (41.4%) without significant differences, three were revised because of incorrect computer programming or wrong accounts. For the rest, the programming was correct and absolute differences were negligible. The applicability was confirmed using the data of 2,730,883 patients and 15,647,468 patient-visits transmitted during 2017-2018, in which 10 (3.5%) tables were corrected. CONCLUSION: Significant magnitude of inconsistent data does exist during the transmission of big data from diverse sources. Systematic validation is essential. Comparing the number of data tabulated using the primary keys allow us to rapidly identify and correct these scattered errors.

Fetomaternal hemorrhage: Evidence from a multihospital healthcare system that up to 40% of severe cases are missed.

BACKGROUND: We previously reported fetomaternal hemorrhage (FMH) in 1/9160 births, and only one neonatal death from FMH among 219,853 births. Recent reports indicate FMH is not uncommon among stillbirths. Consequently, we speculated we were missing cases among early neonatal deaths. We began a new FMH initiative to determine the current incidence. METHODS: We analyzed births from 2011 to 2020 where FMH was diagnosed. We also evaluated potential cases among neonates receiving an emergent transfusion just after birth, whose mothers were not tested for FMH. RESULTS: Among 297,403 births, 1375 mothers were tested for FMH (1/216 births). Fourteen percent tested positive (1/1599 births). Of those, we found 25 with clinical and laboratory evidence of FMH adversely affecting the neonate. Twenty-one received one or more emergency transfusions on the day of birth; all but two lived. We found 17 others who received an emergency transfusion on the day of birth where FMH was not tested for, but was likely; eight of those died. The 42 severe (proven + probable) cases equate to 1/7081 births. We judged that 10 of the 42 had an acute FMH, and in the others it likely had more than a day before birth. CONCLUSIONS: We estimate that we fail to diagnose >40% of our severe FMH cases. Needed improvements include (1) education to request maternal FMH testing when neonates are born anemic, (2) education on false-negative FMH tests, and (3) improved FMH communications between neonatology, obstetrics, and blood bank.

The impact of emergency department observation units on a health system.

IMPORTANCE: Protocol driven ED observation units (EDOU) have been shown to improve outcomes for patients and payers, however their impact on an entire health system is unknown. Two thirds of US hospitals do not have such units. OBJECTIVE: To determine the impact of a protocol-driven EDOU on health system length of stay, cost, and resource utilization. METHODS: A retrospective, observational, cross-sectional study of observation patients managed over 25 consecutive months in a four-hospital academic health system. Patients were identified using the "admit to observation" order and limited to adult, emergent / urgent, non-obstetric patients. Data was retrieved from a cost accounting database. The primary study exposure was the setting for observation care which was broken into three discrete groups: EDOUs (n = 3), hospital medicine observation units (HMSOU, n = 2), and a non-observation unit (NOU) bed located anywhere in the hospital. Outcomes included observation-to-inpatient admission rate, length of stay (LoS), total direct cost, and inpatient bed days saved. Unadjusted outcomes were compared, and outcomes were adjusted using multiple study variables. LoS and cost were compared using quantile regressions. Inpatient admit rate was compared using logistic regressions. RESULTS: The sample consisted of 48,145 patients who were 57.4% female, 48% Black, 46% White, median age of 58, with some variation in most common diagnoses and payer groups. The median unadjusted outcomes favored EDOU over NOU settings for admission rate (13.1% vs 37.1%), LoS [17.9 vs 35.6 h), and cost ($1279 vs $2022). The adjusted outcomes favored EDOU over NOU settings for admission rates [12.3% (95% CI 9.7-15.3) vs 26.4% (CI 21.3-32.3)], LoS differences [11.1 h (CI 10.6-11.5 h)] and cost differences [$127.5 (CI $105.4 - $149.5)]. Adjusted differences were similar and favored EDOU over HMSOU settings. For the health system, the total adjusted annualized savings of the EDOUs was 10,399 bed days and $1,329,443 in total direct cost per year. CONCLUSION: Within an academic medical center, EDOUs were associated with improved resource utilization and reduced cost. This represents a significant opportunity for hospitals to improve efficiency and contain costs.

Burnout and distress among physicians in a cardiovascular centre of a quaternary hospital network: a cross-sectional survey.

BACKGROUND: Burnout and distress have a negative impact on physicians and the treatment they provide. Our aim was to measure the prevalence of burnout and distress among physicians in a cardiovascular centre of a quaternary hospital network in Canada, and compare these outcomes to those for physicians at academic health science centres (AHSCs) in the United States. METHODS: We conducted a survey of physicians practising in a cardiovascular centre at 2 quaternary referral hospitals in Toronto, Ontario, between Nov. 27, 2018, and Jan. 31, 2019. The survey tool included the Well-Being Index (WBI), which measures fatigue, depression, burnout, anxiety or stress, mental and physical quality of life, work-life integration, meaning in work and distress; a score of 3 or higher indicated high distress. We also evaluated physicians' perception of the adequacy of staffing levels and of fair treatment in the workplace, and satisfaction with the electronic health record. We carried out standard univariate statistical comparisons using the χ2, Fisher exact or Kruskal-Wallis test as appropriate to perform univariate comparisons in the sample of respondents. We assessed the relation between a WBI score of 3 or higher and demographic characteristics. We compared univariate associations among WBI data for physicians at AHSCs in the US who completed the WBI to responses from our participants. RESULTS: The response rate to the survey was 84.1% (127/151). Of the 127 respondents, 83 (65.4%) reported burnout in the previous month, and 68 (53.5%) reported emotional problems. Sixty-nine respondents (54.3%) had a WBI score of 3 or higher. Respondents were more likely to have a WBI score of 3 or higher versus a score less than 3 if they perceived insufficient staffing levels (52/69 [75%] v. 26/58 [45%], p = 0.02) or unfair treatment (23/69 [33%] v. 8/58 [14%], p = 0.03), or were anesthesiologists (26/35 [74%] v. 43/92 [47%] for other specialists, p = 0.005). Compared to 21 594 physicians in practice at AHSCs in the US, our respondents had a higher mean WBI score (2.4 v. 1.8, p = 0.004) and reported a higher prevalence of burnout (65.4% v. 56.6%, p = 0.048). INTERPRETATION: Physicians in this study had high levels of burnout and distress, driven by the perception of inadequate staffing levels and being treated unfairly in the workplace. Addressing these institutional factors may improve physicians' work experience and patient outcomes.

Burnout and distress among nurses in a cardiovascular centre of a quaternary hospital network: a cross-sectional survey.

BACKGROUND: Burnout and distress have a negative impact on nurses and the treatment they provide. Our aim was to measure the prevalence of burnout and distress among nurses in a cardiovascular centre at 2 quaternary referral hospitals in Canada, and compare these outcomes to those for nurses at academic health science centres (AHSCs) in the United States. METHODS: We conducted a survey of nurses practising in a cardiovascular centre at 2 quaternary referral hospitals in Toronto, Ontario, between Nov. 27, 2018, and Jan. 31, 2019. The survey tool included the Well-Being Index (WBI), which measures fatigue, depression, burnout, anxiety or stress, mental and physical quality of life, work-life integration, meaning in work and distress; a score of 2 or higher on the WBI indicated high distress. We also evaluated nurses' perception of the adequacy of staffing levels and of fair treatment in the workplace, and satisfaction with the electronic health record. We carried out standard univariate statistical comparisons using the χ2, Fisher exact or Kruskal-Wallis test as appropriate to perform univariate comparisons in the sample of respondents. We assessed the relation between a WBI score of 2 or higher and demographic characteristics. We compared univariate associations among WBI data for nurses at AHSCs in the US who completed the WBI to responses from our participants. RESULTS: The response rate to the survey was 49.1% (242/493). Of the 242 respondents, 188 (77.7%) reported burnout in the previous month; 189 (78.1%) had a WBI score of 2 or higher, and 132 (54.5%) had a score of 4 or higher (indicative of severe distress). Ordinal multivariable analysis showed that lower WBI scores were associated with satisfaction with staffing levels (odds ratio [OR] 0.33, 95% confidence interval [CI] 0.16-0.69) and the perception of fair treatment in the workplace (OR 0.41, 95% CI 0.23-0.74). Higher proportions of our respondents than nurses at AHSCs in the US reported burnout (77.7% v. 60.5%, p < 0.001) and had a WBI score of 2 or higher (78.1% v. 57.0%) or 4 or higher (54.5% v. 32.0%) (both p < 0.001). INTERPRETATION: Although levels of burnout and distress were high among nurses, their perceptions of adequate staffing and fair treatment were associated with lower distress. Addressing inadequate staffing and unfair treatment may decrease burnout and other dimensions of distress among nurses, and improve their work experience and patient outcomes.

Burnout and distress among allied health care professionals in a cardiovascular centre of a quaternary hospital network: a cross-sectional survey.

BACKGROUND: Burnout and distress negatively affect the well-being of health care professionals and the treatment they provide. Our aim was to measure the prevalence of burnout and distress among allied health care staff at a cardiovascular centre of a quaternary hospital network in Canada, and compare outcomes to those for nonphysician employees in the United States. METHODS: We conducted a survey of allied health care staff, including physical, respiratory and occupational therapists, pharmacists, social workers, dietitians and speech-language pathologists, in a cardiovascular centre at 2 quaternary referral hospitals in Toronto, Ontario, between Nov. 27, 2018, and Jan. 31, 2019. The survey tool included the Well-Being Index (WBI), which measures fatigue, depression, burnout, anxiety or stress, quality of life, work-life integration, meaning in work and overall distress; a score of 2 or higher indicated high distress. We carried out standard univariate statistical comparisons using the χ2, Fisher exact or Kruskal-Wallis test as appropriate to perform univariate comparisons in the sample of respondents. We assessed the relation between a WBI score of 2 or higher and demographic characteristics. We compared univariate associations among WBI data for nonphysician employees in the US who completed the WBI to responses from our participants. RESULTS: The response rate to the survey was 86% (45/52). Thirty-three respondents (73%) reported experiencing burnout in the previous month, and 31 (69%) reported emotional problems. Compared to respondents who perceived fair treatment in the workplace, those who perceived unfair treatment (20 [44%]) were more likely to report emotional problems (17 [85%] v. 13 [54%], p = 0.05), to worry that work was hardening them emotionally (15 [75%] v. 8 [33%], p = 0.008), and to feel down, depressed or hopeless (12 [60%] v. 4 [17%], p = 0.005). Twenty-five respondents (56%) and 13 respondents (29%) reported WBI scores consistent with high (≥ 2) or severe (≥ 5) distress, respectively. Respondents were more likely to have a high WBI score if they perceived unfair treatment or inadequate staffing levels. Our respondents had a higher prevalence of burnout (73.3% v. 53.6%, p = 0.008) and a higher average WBI score (2.6 [SD 2.8] v. 1.7 [SD 2.6], p = 0.05) than 9096 nonphysician employees in the US. INTERPRETATION: The prevalence of burnout, emotional problems and distress was high among allied health care staff. Fair treatment in the workplace and adequate staffing may lower distress levels and improve the work experience of these health care professionals.

Impact of COVID-19 on a Neurosurgical Service: Lessons from the University of California San Diego.

BACKGROUND: The institution-wide response of the University of California San Diego Health system to the 2019 novel coronavirus disease (COVID-19) pandemic was founded on rapid development of in-house testing capacity, optimization of personal protective equipment usage, expansion of intensive care unit capacity, development of analytic dashboards for monitoring of institutional status, and implementation of an operating room (OR) triage plan that postponed nonessential/elective procedures. We analyzed the impact of this triage plan on the only academic neurosurgery center in San Diego County, California, USA. METHODS: We conducted a de-identified retrospective review of all operative cases and procedures performed by the Department of Neurosurgery from November 24, 2019, through July 6, 2020, a 226-day period. Statistical analysis involved 2-sample z tests assessing daily case totals over the 113-day periods before and after implementation of the OR triage plan on March 16, 2020. RESULTS: The neurosurgical service performed 1429 surgical and interventional radiologic procedures over the study period. There was no statistically significant difference in mean number of daily total cases in the pre-versus post-OR triage plan periods (6.9 vs. 5.8 mean daily cases; 1-tail P = 0.050, 2-tail P = 0.101), a trend reflected by nearly every category of neurosurgical cases. CONCLUSIONS: During the COVID-19 pandemic, the University of California San Diego Department of Neurosurgery maintained an operative volume that was only modestly diminished and continued to meet the essential neurosurgical needs of a large population. Lessons from our experience can guide other departments as they triage neurosurgical cases to meet community needs.

Reducing Surgery Scheduling Errors in Multihospital System.

OBJECTIVE: The purpose of this study was to assess whether bundled team training interventions for surgeons and office staff could effectively improve the accuracy of surgery scheduling, minimizing scheduling factors that may contribute to occurrence of wrong site surgery. METHODS: This quasi-experimental observational study used an interrupted time series design to explore surgery scheduling errors (SSEs) and implemented bundled team training interventions intended to reduce SSEs at a Pacific Northwest Regional Surgery Scheduling Department. Each preintervention and postintervention segment consisted of 16 weekly data points. The bundled team training interventions included disclosure of preintervention scheduling errors, a scheduling verification checklist, an updated surgery scheduling policy and procedure, and toolkit to improve office scheduling of surgeries. RESULTS: Improvements in SSEs were observed preintervention to postintervention, with decreased surgery SSE rate from 0.51% to 0.13% (P < 0.001). Reductions were observed in all SSE types. The segmented linear trend demonstrated an observed reduction of 42.70 SSE (P < 0.001). CONCLUSIONS: This is the first study conducted at a large healthcare system with a regional surgery scheduling department to demonstrate that statistically significant and clinically important reductions in SSEs can be achieved. The findings demonstrate that SSEs can be minimized and confirm that verification processes must begin in the surgeon's office once a decision has been reached to proceed with surgery. The study confirms the need for additional research targeted at understanding why SSEs occur at the time of scheduling.

Organizational and environmental factors associated with local multihospital systems: Precipitants for coordination?

BACKGROUND: Local multihospital systems (LMSs) commonly struggle to effectively coordinate across system members. Although a recent taxonomy of LMSs found the majority of systems to display lower levels of differentiation, integration, and coordination, some categories of LMS forms exhibited higher levels of integration and coordination. PURPOSE: This study examines organizational and environmental factors associated with LMS forms displaying higher levels of integration and coordination. METHODOLOGY/APPROACH: Applying a multitheoretical framework and drawing from sources including the American Hospital Association Annual Survey, Intellimed databases, and primary data collected from LMS communications, descriptive and multinomial logistic regression analyses were conducted to examine the association between LMS forms and varied organizational and environmental characteristics among LMSs in Florida, Maryland, Nevada, Texas, Virginia, and Washington. RESULTS: The results of analysis of variance, Games-Howell, and Fisher's exact tests identified significant relationships between each of the five LMS categories and varying market, competitive, organizational, and operational factors. A multinomial logistic regression analysis also distinguished the three most common LMS forms according to organizational and environmental factors. CONCLUSION: Recognizing the varied degrees of integration and coordination across LMSs today, the results point to several factors that may explain such variation, including market size and resources, local competitors and their forms, organizational size and ownership, patient complexity, and regulatory restrictions. PRACTICE IMPLICATIONS: With the continued promotion and development of innovative health care reform models and with the progressing expansion of care into outpatient sites and diverse settings, LMSs will continue to face greater pressure to integrate and coordinate services throughout the continuum of care across system components and service locations. Navigating the challenges of effective coordination requires administrators and policymakers to be cognizant of the organizational and environmental factors that may hinder or fuel coordination efforts across system components in local markets.

Implementation of a Centralized Telepsychiatry Consult Service in a Multi-Hospital Metropolitan Health Care System: Challenges and Opportunities.

BACKGROUND: Providing adequate psychiatry consultation capacity on a 24/7 basis is an intrinsic challenge throughout many multihospital health care systems. At present, implementation research has not adequately defined the effectiveness and feasibility of a centralized telepsychiatry consultation service within a multihospital health care system. OBJECTIVE: To demonstrate feasibility of a hub and spoke model for provision of inpatient consult telepsychiatry service from an academic medical center to 2 affiliated regional hospital sites, to reduce patient wait time, and to develop best practice guidelines for telepsychiatry consultations to the acutely medically ill. METHODS: The implementation, interprofessional workflow, process of triage, and provider satisfaction were described from the first 13 months of the service. RESULTS: This pilot study resulted in 557 completed telepsychiatry consults over the course of 13 months from 2018 to 2019. A range of psychiatric conditions commonly encountered by consultation-liaison services were diagnosed and treated through the teleconferencing modality. The most common barriers to successful use of telepsychiatry were defined for the 20% of consult requests that were retriaged to face-to-face evaluation. The average patient wait time from consult request to initial consultation was reduced from >24 hours to 92 minutes. CONCLUSIONS: This study demonstrated the feasibility of a centralized telepsychiatry hub to improve delivery of psychiatry consultation within a multihospital system with an overall reduction in patient wait time. This work may serve as a model for further design innovation across many health care settings and new patient subpopulations.

Low Risk of Hypertrophic Cardiomyopathy With Contemporary Management Strategies Implemented in Non-Referral Regional Community-Based Practices.

Major advances in diagnosis and treatment have emerged for hypertrophic cardiomyopathy (HCM), largely in major tertiary referral centers dedicated to this disease. Whether these therapeutic benefits are confined to patients in such highly selected cohorts, or can be implemented effectively in independent regional or community-based populations is not generally appreciated. We assessed management and clinical outcomes in a non-referral HCM center (n = 214 patients) in Eastern Pennsylvania. Over a 6.0 ± 3.2-year follow-up, the HCM-related mortality rate was 0.1% per year attributed to a single disease-related death, in a 49-year-old man with end-stage heart failure, ineligible for heart transplant. Fifteen patients (7%) with prophylactically placed implantable cardioverter-defibrillators (ICDs) experienced appropriate therapy terminating life-threatening ventricular tachyarrhythmias. In 23 other patients (11%; 5%/year), heart failure due to left ventricular outflow obstruction was reversed by surgical septal myectomy (n = 20) or percutaneous alcohol septal ablation (n = 3). This regional HCM cohort was similar to a comparison tertiary center referral population in terms of HCM-mortality: 0.1%/year vs 0.3%/year (p = 0.3) and ICD therapy (31% vs 16% of primary prevention implants), although more frequently with uncomplicated benign clinical course (62% vs 46%; p <0.01). In conclusion, effective contemporary HCM management strategies and outcomes in referral-based HCM centers can be successfully replicated in regional and/or non-referral settings. Therefore, HCM is now a highly treatable disease compatible with normal longevity when assessed in a variety of clinical venues not limited to tertiary centers.

Stroke Care in the First Affiliated Hospital of Chengdu Medical College during the COVID-19 Outbreak.

Coronavirus disease-2019 (COVID-19) has become a pandemic disease globally. The First Affiliated Hospital of Chengdu Medical College has adopted telestroke to make stroke care accessible in remote areas. During the period January 2020 to March 2020, there was no COVID-19 case reported in our stroke center. A significant reduction of stroke admission was observed between the ischemic stroke group (235 vs. 588 cases) and the intracerebral hemorrhage group (136 vs. 150 cases) when compared with the same period last year (p < 0.001). The mean door-to-needle time (DNT) and door-to-puncture time (DPT) was 62 and 124 min, respectively. Compared to the same period last year, a significant change was observed in DNT (62 ± 12 vs. 47 ± 8 min, p = 0.019) but not in DPT (124 ± 58 vs. 135 ± 23 min, p = 0.682). A total of 46 telestroke consultations were received from network hospitals. Telestroke management in the central hospital was performed on 17 patients. Of them, 3 (17.6%) patients had brain hernia and died in hospital and 8 (47.1%) patients were able to ambulation at discharge and had a modified Rankin Scale of 0-2 at 3 months. The COVID-19 pandemic impacted stroke care significantly in our hospital, including prehospital and in-hospital settings, resulting in a significant drop in acute ischemic stroke admissions and a delay in DNT. The construction of a telestroke network enabled us to extend health-care resources and make stroke care accessible in remote areas. Stroke education and public awareness should be reinforced during the COVID-19 pandemic.

In-hospital care in acute heart failure during the COVID-19 pandemic: insights from the German-wide Helios hospital network.

AIMS: The coronavirus disease 2019 (COVID-19) pandemic has led to changes in health care utilization for different acute cardiovascular diseases. Whether hospitalization rates and in-hospital mortality were affected by the pandemic in patients with acute symptomatic heart failure (HF) was investigated in this study. METHODS AND RESULTS: Administrative data provided by 67 German Helios hospitals were examined for patients with a main discharge diagnosis of HF using ICD codes. Urgent hospital admissions per day were compared for a study period (13 March-21 May 2020) with control intervals in 2020 (1 January-12 March) and 2019 (13 March-21 May), resulting in a total of 13 484 patients excluding all patients with laboratory-proven COVID-19 infection. Incidence rate ratios (IRR) were calculated using Poisson regression. Generalized linear mixed models were used for univariable and multivariable analysis to identify predictors of in-hospital mortality. The number of admissions per day was lower in the study period compared to the same year [IRR 0.69, 95% confidence interval (CI) 0.67-0.73, P < 0.01] and the previous year control group (IRR 0.73, 95% CI 0.70-0.76, P < 0.01). Age was similar throughout the intervals, but case severity increased in terms of distribution within New York Heart Association (NYHA) classes and comorbidities. Within the study period, 30-day rates for urgent hospital readmissions were higher compared to the same year but not the previous year control group. In-hospital mortality was 7.3% in the study period, 6.1% in the same year (P = 0.03) and 6.0% in the previous year control group (P = 0.02). In multivariable analysis, age, NYHA class and other predictors of fatal outcome were identified but hospitalization during the study period was not independently associated with mortality. CONCLUSION: Our data showed a significant reduction of urgent hospital admissions for HF with increased case severity and concomitant in-hospital mortality during the COVID-19 pandemic in Germany. Identifying causes of reduced inpatient treatment rates is essential for the understanding and valuation with regard to future optimal management of patients with HF.

Integration and Standardization of Clinical Nurse Specialists in a Multihospital System: Exemplars in Practice.

PURPOSES/OBJECTIVES: In 2013, our multihospital system began the process to integrate and standardize clinical nurse specialist (CNS) practice. The goal was to standardize work and to increase collaboration as part of one system. DESCRIPTION OF THE PROJECT/PROGRAM: An overall job description was established to provide a framework inclusive of the broad areas of practice. Clinical nurse specialists were positioned to support medical-surgical, critical care, or women and children's services offered at community-based hospitals. Main campus and community-based CNSs led significant system integration efforts such as the standardization of nursing policies and procedures across the health system. System CNSs were created to address the needs of specialties common to all hospitals. As an example, a system CNS collaborated with the main campus and community-based CNSs to improve the delirium screening process. OUTCOME: Clinical nurse specialists across the system have been integrated into a single team and report to 1 central director. Efforts to leverage expertise included the creation of a CNS-led practice council, increased communication via regular departmental meetings, and the sharing of resources using electronic platforms. There is now a CNS at hospitals that previously did not have one. The group values the structure and opportunities it provides as evidenced by favorable engagement surveys. CONCLUSION: Our integration efforts improved collaboration and could be modified to benefit other care settings.

Consolidation of obstetric services in a public health emergency.

Though much of routine healthcare pauses in a public health emergency, childbirth continues uninterrupted. Crises like COVID-19 put incredible strains on healthcare systems and require strategic planning, flexible adaptability, clear communication, and judicious resource allocation. Experiences from obstetric units affected by COVID-19 highlight the importance of developing new teams and workflows to ensure patient and healthcare worker safety. Additionally, adapting a strategy that combines units and staff from different areas and hospitals can allow for synergistic opportunities to provision care appropriately to manage a structure and workforce at maximum capacity.