Efficacy and Safety of Pediatric Critical Care Physician Telemedicine Involvement in Rapid Response Team and Code Response in a Satellite Facility.

OBJECTIVES: Satellite inpatient facilities of larger children's hospitals often do not have on-site intensivist support. In-house rapid response teams and code teams may be difficult to operationalize in such facilities. We developed a system using telemedicine to provide pediatric intensivist involvement in rapid response team and code teams at the satellite facility of our children's hospital. Herein, we compare this model with our in-person model at our main campus. DESIGN: Cross-sectional. SETTING: A tertiary pediatric center and its satellite facility. PATIENTS: Patients admitted to the satellite facility. INTERVENTIONS: Implementation of a rapid response team and code team model at a satellite facility using telemedicine to provide intensivist support. MEASUREMENTS AND MAIN RESULTS: We evaluated the success of the telemedicine model through three a priori outcomes: 1) reliability: involvement of intensivist on telemedicine rapid response teams and codes, 2) efficiency: time from rapid response team and code call until intensivist response, and 3) outcomes: disposition of telemedicine rapid response team or code calls. We compared each metric from our telemedicine model with our established main campus model. MAIN RESULTS: Critical care was involved in satellite campus rapid response team activations reliably (94.6% of the time). The process was efficient (median response time 7 min; mean 8.44 min) and effective (54.5 % patients transferred to PICU, similar to the 45-55% monthly rate at main campus). For code activations, the critical care telemedicine response rate was 100% (6/6), with a fast response time (median 1.5 min). We found no additional risk to patients, with no patients transferred from the satellite campus requiring a rapid escalation of care defined as initiation of vasoactive support, greater than 60 mL/kg in fluid resuscitation, or endotracheal intubation. CONCLUSIONS: Telemedicine can provide reliable, timely, and effective critical care involvement in rapid response team and Code Teams at satellite facilities.

Analysis of Patient Visits and Collections After Opening a Satellite Pediatric Emergency Department.

OBJECTIVE: Satellite pediatric emergency departments (PEDs) have emerged as a strategy to increase patient capacity. We sought to determine the impact on patient visits, physician fee collections, and value of emergency department (ED) time at the primary PED after opening a nearby satellite PED. We also illustrate the spatial distribution of patient demographics and overlapping catchment areas for the primary and satellite PEDs using geographical information system. METHODS: A structured, financial retrospective review was conducted. Aggregate patient demographic data and billing data were collected regarding physician fee charges, collections, and patient visits for both PEDs. All ED visits from January 2009 to December 2013 were analyzed. Geographical information system mapping using ArcGIS mapped ED patient visits. RESULTS: Patient visits at the primary PED were 53,050 in 2009 before the satellite PED opened. The primary PED visits increased after opening the satellite PED to 55,932 in 2013. The satellite PED visits increased to 21,590 in 2013. Collections per visit at the primary PED decreased from $105.13 per visit in 2011 to $86.91 per visit in 2013. Total collections at the satellite PED decreased per visit from $155.41 per visit in 2011 to $128.53 per visit in 2013. CONCLUSIONS: After opening a nearby satellite PED, patient visits at the primary PED did not substantially decrease, suggesting that there was a previously unrecognized demand for PED services. The collections per ED visit were greater at the satellite ED, likely due to a higher collection rate.

[Teledialysis in satellite hospital: 5-year practice in Saint-Brieuc]. / Hémodialyse en unité de dialyse médicalisée télésurveillée: une expérience de cinq années.

The ageing population, the need for patient care delivery closer to home and reducing travel cost and isolation and, not at least, optimising medical team activity lead to adapt treatment by hemodialysis. Telehealth is an alternative now enabled by recent regulatory changes. We summarize here the regulatory and organisational conditions in a monitored Medicalized Dialysis Unit (MDU) and report the local experience of Saint-Brieuc Hospital; the feasibility and functionality over time (5 years) of this approach was demonstrated in clinical practice with selected patients; over short-term and for a still-limited number of patients, its clinical results are comparable to those observed in a MDU running on a traditional regimen (weekly visits and on-call 24 hours on-site 24 of the nephrologist); the degree of patient satisfaction, some of them very old people, is high. Stability of communications mainly depending of the operators and audio-video quality needed for a friendly and efficient exchange, could be improved. Relevant analysis of cost is necessary to adjust compensation and to encourage the deployment of teledialysis. The development of this technique is suitable in order to maintain oldering populations close to home, to assure the fairest access to medical care and to serve its purpose, which is the care in all its dimensions.

The effects of increased provision of thoracic surgical specialists on the variation in lung cancer resection rate in England.

INTRODUCTION: There is a wide variation in the lung cancer resection rate in England. We assessed the effect of the regional provision of thoracic surgery service on the variation in lung cancer resection rate. METHODS: A retrospective observational study correlating National Lung Cancer Audit data with thoracic surgery workforce data was performed to review the lung cancer resection rate in England in 2008 and 2009. RESULTS: In 2008, there was a sixfold variation in resection rate, with a higher resection rate in hospitals where surgeons were based (base hospitals) than in peripheral hospitals (20.0% versus 11.6%, p < 0.001). The resection rate was also higher in cancer networks, which were served by two or more specialist thoracic surgeons (14.6% versus 12.7%, p = 0.028), and where surgeons were present in more than two-thirds of the lung cancer multidisciplinary team meetings (14.4% versus 12.0%, p = 0.046). In 2009, the overall resection rate increased from 14.5% to 18.4%. Four units increased their number of specialist thoracic surgeons and had a significantly higher increase in resection rate than units without expansion (relative rise 66.3% versus 19.2%; p = 0.022). CONCLUSIONS: The large variation in the resection rate seems, in part, to be related to the local availability of specialist thoracic surgeons. The greatest improvement in the resection rate was in units with expansion of specialist thoracic surgeons. We suggest the expansion of specialist thoracic surgeons will improve the resection rate and thereby the overall survival of lung cancer in England. This has significant implications for the future of training in cardiothoracic surgery and organization of cancer services.

Analysis of the impact of deprivation on urgent suspected head and neck cancer referrals in the Mersey region between January 2004 to December 2006.

Serious delay in patients presenting with head and neck cancer is associated with poor outcomes. We aimed to examine the influence of deprivation on professional delay in the Mersey region from 2004 to 2006. The study sample comprised 6681 patients who were referred between January 2004 and December 2006. The dataset was dominated by the largest hospital (H1), which received 48% of all cases. Median referral overall was 12 days (IQR 8-15 days), and 74% of patients were referred in 14 days or less. Professional delay (percentage 14 days or less) was associated with hospital (from 58% H1 to 97% H5), year of referral (from 64% in 2004 to 80% in 2006), age (from 69% under 55 years to 80% over 75 years), and deprivation (Index of Multiple Deprivation 2000 from 67% most deprived (IMD 1) to 85% least deprived (IMD 5)). Hospital location was associated with these factors and the results imply that by far, the most important variable in predicting professional delay was the hospital that received the referral. Trends over time in age, and to a lesser extent, for deprivation were noted in H1, but were largely absent across other hospitals. Some of them needed to make substantial improvements to meet the two-week referral pathway and it would be interesting to compare these results with current practice. This study highlights the importance of maintaining the standards of the current policy on two-week referrals for suspected head and neck malignancy.

Financial consequences of implementing a partner-in-care in cardiac surgery.

BACKGROUND: In 2003, a satellite cardiac surgery program (SAT) was implemented at an affiliated community hospital located in an area historically served by an academic medical center (AMC). This study assessed the financial consequences and the changes in case-mix that occurred at the AMC after SAT implementation. METHODS: From June 2002 through December 2005, 4593 adult patients underwent cardiac operations at the AMC. Excluded were 400 patients operated on during the 4-month transition period after SAT implementation and 1210 patients living more than 35 miles from the AMC. Multivariable regression was used to compare changes in case-mix and propensity-score adjusted costs for AMC patients referred from SAT area (N(before/after =) 328/291) vs other patients (N(before/after =) 897/1467). RESULTS: The SAT area referral rate decreased by 55%. Compared with other patients, AMC patients referred from the SAT area showed a greater increase in age in the second period (p = 0.013). The nursing workload and adjusted mean costs increased more for patients from the SAT area (p = 0.015 and 0.014, respectively). The hospital margin decreased in the second period for both referral areas (p < 0.001). For the patient subgroup undergoing coronary artery bypass grafting, this hospital margin decrease was greater for SAT area patients (p = 0.017). CONCLUSIONS: After implementation of SAT program, fewer patients of lower complexity came to the AMC from the SAT area, and there was a significant increase in nursing workload and costs. During this interval, hospital margin for cardiac operations decreased from both referral areas but decreased significantly more for coronary artery bypass graft patients from the SAT area.

Análisis retrospectivo de operaciones de cataratas efectuadas en el Hospital Regional de Temuco en comparación con operaciones efectuadas en hospitales periféricos de la novena región / Retrospective analysis of cataract surgeries carried out in Hospital Regional de Temuco and the satellite hospitals of the ninth region

Se realizó un análisis retrospectivo de 518 cirugías de catara. 431 (83 por ciento) de ellas fueron hechas en el hospital Regional y 87 (17 por ciento) en hospitales periféricos: En las cirugías participaron 12 cirujanos del staff entre el año 1996 y 2001. El 90 por ciento de los pacientes fue operado en los años 1999 y 2000. Cuatro cirujanos operaron el 70 por ciento de los pacientes estudiados. El 52.5 por ciento fue operado con técnica extracapsular y el 47.5 por ciento con facoemulsificación. El 37.1 por ciento fueron hombres y el 62.9 mujeres. El promedio de edad fue de 70.5 años con una mínima de 6 años y una máxima de 96. El 53.1 por ciento ojos derechos y el 46.9 por ciento ojos izquierdos. El 27.6 por ciento tuvo complicaciones. 1 por ciento desprendimiento de retina (DR), 1.7 por ciento hipertensión, 6.2 por ciento opacidad de la cápsula posterior (OCP), 4.6 por ciento rotura cápsula posterior (RCP), 5.8 por ciento RCP más vitrectomía anterior, 2.3 por ciento iritis, 0.13 por ciento endoftalmitis. Las visiones pre operatorias eran en un 77.4 por ciento menos de 0.2 y el 22.6 por ciento entre 0.25 y 0.40 y las post operatorias 9.3 por ciento quedaron bajo 0.2 un 12.7 por ciento entre 0.25 y 0.4 y un 78 por ciento entre 0.5 y 1.0. El promedio de las visiones para los pre operados es de 0.14 con un rango de 0.04 al 0.40. El promedio para los post operados es de 0.56 con un rango de 0.04 al 1.0. Para evaluar el resultado de la operación se construye un incremento de la visión (vpost-vpre). Este incremento tiene un promedio de 0.421 y es significativo. Existe una diferencia significativa entre el incremento de la visión después de la operación de los pacientes operados dentro del hospital mayor que los operados fuera del hospital. Las complicaciones de las cirugías en los hospitales periféricos (17.2 por ciento) son menores estadísticamente que las efectuadas en el hospital Regional (29.7 por ciento). Objetivo: Analizar la posibilidad de efectuar operaciones de cataratas en la IX Región en un hospital distinto del Hospital Regional de Temuco, sin que eso significara riesgo para el paciente o malos resultados visuales.

Magnitud y características de la consulta externa atendida por médico generalista en centros sanitarios periféricos / Ambulatory care by general practitioners

Se aborda la problemática de la relación entre médicos generalistas y especialistas y su disociación con las frecuecias de las patologías susceptibles de ser resueltas en el Primer Nivel de atención (80 a 93,5 por ciento). El objetivo formulado para esta primera etapa del estudio consiste en establecer la magnitud y las características de la consulta atendida por médico generalista a nivel de centros de salud situados en la periferia de la ciudad de La Plata (Argentina). El volumen más importante de consultas se ubicó dentro de las causadas por morbilidad. La demanda predominante responde a patologías propias de las condiciones de vida, con amplio predominio de infecciones respiratorias, seguidas por las gastrointestinales. Por otro lado, los controles se hallan predominantemente referidos al binomio materno-infantil, observándose una reducida carga de exámenes de salud, propios del adulto. La concentración de consultas resulta sumamente reducida como consecuencia del modelo prestacional vigente, el que carece de capacidad de retención. Los controles representan algo más del 20 por ciento de la demanda, con una concentración un poco más alta. El predominio de la demanda femenina es notorio, pero deben ser contempladas las causas obstétricas a fin de establecer el alcance genuino de esta preponderancia

Magnitud y características de la consulta externa atendida por médico generalista en centros sanitarios periféricos / Ambulatory care by general practitioners

Se aborda la problemática de la relación entre médicos generalistas y especialistas y su disociación con las frecuecias de las patologías susceptibles de ser resueltas en el Primer Nivel de atención (80 a 93,5 por ciento). El objetivo formulado para esta primera etapa del estudio consiste en establecer la magnitud y las características de la consulta atendida por médico generalista a nivel de centros de salud situados en la periferia de la ciudad de La Plata (Argentina). El volumen más importante de consultas se ubicó dentro de las causadas por morbilidad. La demanda predominante responde a patologías propias de las condiciones de vida, con amplio predominio de infecciones respiratorias, seguidas por las gastrointestinales. Por otro lado, los controles se hallan predominantemente referidos al binomio materno-infantil, observándose una reducida carga de exámenes de salud, propios del adulto. La concentración de consultas resulta sumamente reducida como consecuencia del modelo prestacional vigente, el que carece de capacidad de retención. Los controles representan algo más del 20 por ciento de la demanda, con una concentración un poco más alta. El predominio de la demanda femenina es notorio, pero deben ser contempladas las causas obstétricas a fin de establecer el alcance genuino de esta preponderancia (AU)