In Situ Simulation for Adoption of New Technology to Improve Sepsis Care in Rural Emergency Departments.

OBJECTIVES: The aims of the study were to evaluate whether in situ (on-site) simulation training is associated with increased telemedicine use for patients presenting to rural emergency departments (EDs) with severe sepsis and septic shock and to evaluate the association between simulation training and telehealth with acute sepsis bundle (SEP-1) compliance and mortality. METHODS: This was a quasi-experimental study of patients presenting to 2 rural EDs with severe sepsis and/or septic shock before and after rollout of in situ simulation training that included education on sepsis management and the use of telehealth. Unadjusted and adjusted analyses were conducted to describe the association of simulation training with sepsis process of care markers and with mortality. RESULTS: The study included 1753 patients, from 2 rural EDs, 629 presented before training and 1124 presented after training. There were no differences in patient characteristics between the 2 groups. Compliance with several SEP-1 bundle components improved after training: antibiotics within 3 hours, intravenous fluid administration, repeat lactic acid assessment, and vasopressor administration. The use of telemedicine increased from 2% to 5% after training. Use of telemedicine was associated with increases in repeat lactic acid assessment and reassessment for septic shock. We did not demonstrate an improvement in mortality across either of the 2 group comparisons. CONCLUSIONS: We demonstrate an association between simulation and improved care delivery. Implementing an in situ simulation curriculum in rural EDs was associated with a small increase in the use of telemedicine and improvements in sepsis process of care markers but did not demonstrate improvement in mortality. The small increase in telemedicine limited conclusions on its impact.

A novel in situ simulation framework for introduction of a new technology: the 3-Act-3-Debrief model.

BACKGROUND: New technologies for clinical staff are typically introduced via an "in-service" that focuses on knowledge and technical skill. Successful adoption of new healthcare technologies is influenced by multiple other factors as described by the Consolidated Framework in Implementation Research (CFIR). A simulation-based introduction to new technologies provides opportunity to intentionally address specific factors that influence adoption. METHODS: The new technology proposed for adoption was a telehealth cart that provided direct video communication with electronic intensive care unit (eICU) staff for a rural Emergency Department (ED). A novel 3-Act-3-Debrief in situ simulation structure was created to target predictive constructs from the CFIR and connect debriefing to specific workflows. The structure and content of the simulation in relation to the framework is described. Participants completed surveys pre-simulation/post-simulation to measure change in their readiness to adopt the new technology. RESULTS: The scenario was designed and pilot tested before implementation at two rural EDs. There were 60 interprofessional participants across the 2 sites, with 58 pre-simulation and 59 post-simulation surveys completed. The post-simulation mean ratings for each readiness measure (feasibility, quality, resource availability, role clarity, staff receptiveness, and tech usability) increased significantly as a result of the simulation experience. CONCLUSIONS: A novel 3-stage simulation-debriefing structure positively targets factors influencing the adoption of new healthcare technologies.

Sepsis Alerts in Emergency Departments: A Systematic Review of Accuracy and Quality Measure Impact.

INTRODUCTION: For early detection of sepsis, automated systems within the electronic health record have evolved to alert emergency department (ED) personnel to the possibility of sepsis, and in some cases link them to suggested care pathways. We conducted a systematic review of automated sepsis-alert detection systems in the ED. METHODS: We searched multiple health literature databases from the earliest available dates to August 2018. Articles were screened based on abstract, again via manuscript, and further narrowed with set inclusion criteria: 1) adult patients in the ED diagnosed with sepsis, severe sepsis, or septic shock; 2) an electronic system that alerts a healthcare provider of sepsis in real or near-real time; and 3) measures of diagnostic accuracy or quality of sepsis alerts. The final, detailed review was guided by QUADAS-2 and GRADE criteria. We tracked all articles using an online tool (Covidence), and the review was registered with PROSPERO registry of reviews. A two-author consensus was reached at the article choice stage and final review stage. Due to the variation in alert criteria and methods of sepsis diagnosis confirmation, the data were not combined for meta-analysis. RESULTS: We screened 693 articles by title and abstract and 20 by full text; we then selected 10 for the study. The articles were published between 2009-2018. Two studies had algorithm-based alert systems, while eight had rule-based alert systems. All systems used different criteria based on systemic inflammatory response syndrome (SIRS) to define sepsis. Sensitivities ranged from 10-100%, specificities from 78-99%, and positive predictive value from 5.8-54%. Negative predictive value was consistently high at 99-100%. Studies showed some evidence for improved process-of-care markers, including improved time to antibiotics. Length of stay improved in two studies. One low quality study showed improved mortality. CONCLUSION: The limited evidence available suggests that sepsis alerts in the ED setting can be set to high sensitivity. No high-quality studies showed a difference in mortality, but evidence exists for improvements in process of care. Significant further work is needed to understand the consequences of alert fatigue and sensitivity set points.

A Simple Low-Cost Method to Integrate Telehealth Interprofessional Team Members During In Situ Simulation.

INTRODUCTION: With the growth of telehealth, simulation personnel will be called upon to support training that integrates these new technologies and processes. We sought to integrate remote telehealth electronic intensive care unit (eICU) personnel into in situ simulations with rural emergency department (ED) care teams. We describe how we overcame technical challenges of creating shared awareness of the patient's condition and the care team's progress among those executing the simulation, the care team, and the eICU. METHODS: The objective of the simulations was to introduce telehealth technology and new processes of engaging the eICU via telehealth during sepsis care in 2 rural EDs. Scenario development included experts in sepsis, telehealth, and emergency medicine. We describe the operational systems challenges, alternatives considered, and solutions used. Participants completed surveys on self-confidence presimulation/postsimulation in using telehealth and in managing patients with sepsis (1-10 Likert scale, with 10 "completely confident"). Pre-post responses were compared by two-tailed paired t test. RESULTS: We successfully engaged the staff of two EDs: 42 nurses, 9 physicians or advanced practice providers, and 9 technicians (N = 60). We used a shared in situ simulation clinical actions observational checklist, created within an off-the-shelf survey software program, completed during the simulations by an on-site observer, and shared with the eICU team via teleconferencing software, to message and cue eICU nurse engagement. The eICU nurse also participated in debriefing via the telehealth video system with successful simulation engagement. These solutions avoided interfering with real ED or eICU operations. The postsimulation mean ± SD ratings of confidence using telehealth increased from 5.3 ± 2.9 to 8.9 ± 1.1 (Δ3.5, P < 0.05) and in managing patients with sepsis increased from 7.1 ± 2.5 to 8.9 ± 1.1 (Δ1.8, P < 0.05). CONCLUSIONS: We created shared awareness between remote eICU personnel and in situ simulations in rural EDs via a low-cost method using survey software combined with teleconferencing methods.

Emergency Department-Based Palliative Interventions: A Novel Approach to Palliative Care in the Emergency Department.

Background: Patients with cancer and palliative care needs frequently use the emergency department (ED). ED-based palliative services may extend the reach of palliative care for these patients. Objective: To assess the feasibility and reach of an ED-based palliative intervention (EPI) program. Design: A cross-sectional descriptive study of ED patients with active cancer from January 2017 to August 2017. Subjects: Patients with palliative care needs were identified using an abbreviated 5-question version of the screen for palliative and end-of-life care needs in the ED (5-SPEED). Patients with palliative care needs were then automatically flagged for an EPI as determined by their identified need. Measurements: The primary outcome was the prevalence of palliative care needs among patients with active cancer. Secondary outcomes were the rate of EPI services successfully delivered to ED patients with unmet palliative care needs, ED length of stay (LOS), and repeat ED visits within the next 10 days. Categorical variables were evaluated using chi-squared or Fischer's exact test as appropriate. Continuous variables were evaluated using analysis of variance. Results: Of the 1278 patients with active cancer, 817 (63.9%) completed the 5-SPEED screen. Of the patients who completed the screen, 422 patients (51.7%) had one or more unmet palliative care needs and 167 (39.6%) received an EPI. There were no differences in ED LOS or 10-day repeat ED visit rates between patients who did or did not receive an EPI. Conclusion: This ED-based intervention successfully screened for palliative needs in cancer patients and improved access to specific palliative services without increasing ED LOS.

Inpatient Trauma Mortality after Implementation of the Affordable Care Act in Illinois.

INTRODUCTION: Illinois hospitals have experienced a marked decrease in the number of uninsured patients after implementation of the Affordable Care Act (ACA). However, the full impact of health insurance expansion on trauma mortality is still unknown. The objective of this study was to determine the impact of ACA insurance expansion on trauma patients hospitalized in Illinois. METHODS: We performed a retrospective cohort study of 87,001 trauma inpatients from third quarter 2010 through second quarter 2015, which spans the implementation of the ACA in Illinois. We examined the effects of insurance expansion on trauma mortality using multivariable Poisson regression. RESULTS: There was no significant difference in mortality comparing the post-ACA period to the pre-ACA period incident rate ratio (IRR)=1.05 (95% confidence interval [CI] [0.93-1.17]). However, mortality was significantly higher among the uninsured in the post-ACA period when compared with the pre-ACA uninsured population IRR=1.46 (95% CI [1.14-1.88]). CONCLUSION: While the ACA has reduced the number of uninsured trauma patients in Illinois, we found no significant decrease in inpatient trauma mortality. However, the group that remains uninsured after ACA implementation appears to be particularly vulnerable. This group should be studied in order to reduce disparate outcomes after trauma.

Emergency Department Use across 88 Small Areas after Affordable Care Act Implementation in Illinois.

INTRODUCTION: This study analyzes changes in hospital emergency department (ED) visit rates before and after the 2014 Affordable Care Act (ACA) insurance expansions in Illinois. We compare the association between population insurance status change and ED visit rate change between a 24-month (2012-2013) pre-ACA period and a 24-month post-ACA (2014-2015) period across 88 socioeconomically diverse areas of Illinois. METHODS: We used annual American Community Survey estimates for 2012-2015 to obtain insurance status changes for uninsured, private, Medicaid, and Medicare (disability) populations of 88 Illinois Public Use Micro Areas (PUMAs), areas with a mean of about 90,000 age 18-64 residents. Over 12 million ED visits to 201 non-federal Illinois hospitals were used to calculate visit rates by residents of each PUMA, using population-based mapping weights to allocate visits from zip codes to PUMAs. We then estimated n=88 correlations between population insurance-status changes and changes in ED visit rates per 1,000 residents comparing the two years before and after ACA implementation. RESULTS: The baseline PUMA uninsurance rate ranged from 6.7% to 41.1% and there was 4.6-fold variation in baseline PUMA ED visit rates. The top quartile of PUMAs had >21,000 reductions in uninsured residents; 16 PUMAs had at least a 15,000 person increase in Medicaid enrollment. Compared to 2012-2013, 2014-2015 average monthly ED visits by the uninsured dropped 42%, but increased 42% for Medicaid and 10% for the privately insured. Areas with the largest increases in Medicaid enrollment experienced the largest growth in ED use; change in Medicaid enrollment was the only significant correlate of area change in total ED visits and explained a third of variation across the 88 PUMAs. CONCLUSION: ACA implementation in Illinois accelerated existing trends towards greater use of hospital ED care. It remains to be seen whether providing better access to primary and preventive care to the formerly uninsured will reduce ED use over time, or whether ACA insurance expansion is a part of continued, long-term growth. Monitoring ED use at the local level is critical to the success of new home- and community-based care coordination initiatives.

Increased Emergency Department Use in Illinois After Implementation of the Patient Protection and Affordable Care Act.

STUDY OBJECTIVE: We examine emergency department (ED) use and hospitalizations through the ED after Patient Protection and Affordable Care Act (ACA) health insurance expansion in Illinois, a Medicaid expansion state. METHODS: Using statewide hospital administrative data from 2011 through 2015 from 201 nonfederal Illinois hospitals for patients aged 18 to 64 years, mean monthly ED visits were compared before and after ACA implementation by disposition from the ED and primary payer. Visit data were combined with 2010 to 2014 census insurance estimates to compute payer-specific ED visit rates. Interrupted time-series analyses tested changes in ED visit rates and ED hospitalization rates by insurance type after ACA implementation. RESULTS: Average monthly ED visit volume increased by 14,080 visits (95% confidence interval [CI] 4,670 to 23,489), a 5.7% increase, after ACA implementation. Changes by payer were as follows: uninsured decreased by 24,158 (95% CI -27,037 to -21,279), Medicaid increased by 28,746 (95% CI 23,945 to 33,546), and private insurance increased by 9,966 (95% 6,241 to 13,690). The total monthly ED visit rate increased by 1.8 visits per 1,000 residents (95% CI 0.6 to 3.0). The monthly ED visit rate decreased by 8.7 visit per 1,000 uninsured residents (95% CI -11.1 to -6.3) and increased by 10.2 visit per 1,000 Medicaid beneficiaries (95% CI 4.4 to 16.1) and 1.3 visits per 1,000 privately insured residents (95% CI 0.6 to 1.9). After adjusting for baseline trends and season, these changes remained statistically significant. The total number of hospitalizations through the ED was unchanged. CONCLUSION: ED visits by adults aged 18 to 64 years in Illinois increased after ACA health insurance expansion. The increase in total ED visits was driven by an increase in visits resulting in discharge from the ED. A large post-ACA increase in Medicaid visits and a modest increase in privately insured visits outpaced a large reduction in ED visits by uninsured patients. These changes are larger than can be explained by population changes alone and are significantly different from trends in ED use before ACA implementation.

Emergency Department Visits and Hospitalizations for the Uninsured in Illinois Before and After Affordable Care Act Insurance Expansion.

We describe changes in emergency department (ED) visits and the proportion of patients with hospitalizations through the ED classified as Ambulatory Care Sensitive Hospitalization (ACSH) for the uninsured before (2011-2013) and after (2014-2015) Affordable Care Act (ACA) health insurance expansion in Illinois. Hospital administrative data from 201 non-federal Illinois hospitals for patients age 18-64 were used to analyze ED visits and hospitalizations through the ED. ACSH was defined using Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators (PQIs). Logistic regression was used to test the effect of time period on the odds of an ACSH for uninsured Illinois residents, controlling for patient sociodemographic characteristics, weekend visits and state region. Total ED visits increased 5.6% in Illinois after ACA implementation, with virtually no change in hospital admissions. Uninsured ED visits declined from 22.9% of all visits pre-ACA to 12.5% in 2014-2015, reflecting a 43% decline in average monthly ED visits and 54% in ED hospitalizations. The proportion of uninsured ED hospitalizations classified as ACSH increased from 15.4 to 15.5%, a non-significant difference. Older uninsured female, minority and downstate Illinois patients remained significantly more likely to experience ACSH throughout the study period. ED visits for the uninsured declined dramatically after ACA implementation in Illinois but over 12% of ED visits are for the remaining uninsured. The proportion of visits resulting in ACSH remained stable. Providing universal insurance with care coordination focused on improved access to home and ambulatory care could be highly cost effective.

Characterizing Teamwork in Cardiovascular Care Outcomes: A Network Analytics Approach.

BACKGROUND: The nature of teamwork in healthcare is complex and interdisciplinary, and provider collaboration based on shared patient encounters is crucial to its success. Characterizing the intensity of working relationships with risk-adjusted patient outcomes supplies insight into provider interactions in a hospital environment. METHODS AND RESULTS: We extracted 4 years of patient, provider, and activity data for encounters in an inpatient cardiology unit from Northwestern Medicine's Enterprise Data Warehouse. We then created a provider-patient network to identify healthcare providers who jointly participated in patient encounters and calculated satisfaction rates for provider-provider pairs. We demonstrated the application of a novel parameter, the shared positive outcome ratio, a measure that assesses the strength of a patient-sharing relationship between 2 providers based on risk-adjusted encounter outcomes. We compared an observed collaboration network of 334 providers and 3453 relationships to 1000 networks with shared positive outcome ratio scores based on randomized outcomes and found 188 collaborative relationships between pairs of providers that showed significantly higher than expected patient satisfaction ratings. A group of 22 providers performed exceptionally in terms of patient satisfaction. Our results indicate high variability in collaboration scores across the network and highlight our ability to identify relationships with both higher and lower than expected scores across a set of shared patient encounters. CONCLUSIONS: Satisfaction rates seem to vary across different teams of providers. Team collaboration can be quantified using a composite measure of collaboration across provider pairs. Tracking provider pair outcomes over a sufficient set of shared encounters may inform quality improvement strategies such as optimizing team staffing, identifying characteristics and practices of high-performing teams, developing evidence-based team guidelines, and redesigning inpatient care processes.