The Impact of a Concierge Medicine Model on Door to Doctor Time and Patient Flow in an Urban Emergency Department.

INTRODUCTION: Emergency Department (ED) crowding negatively impacts patient outcomes, patient satisfaction, and patient safety. One solution involves introducing a Concierge Physician (CP) whose sole purpose is to provide a brief initial assessment (BIA) and aid patient navigation through the ED. The goal of this study was to quantify the impact of a CP on patient flow dynamics in an urban ED setting. METHODS: We performed a retrospective observational cohort study in an urban academic ED over a 6-month period. Initially, the CP was present in the treatment area during weekdays; during the last half of the observation period, an additional CP was added to the waiting room on weekends. We identified four major milestones in the ED visit with regards to patient throughput. Adult patients presenting to the ED with a triage level of Urgent (ESI 3) were analyzed for this study. Data were stratified based on the patient's ultimate disposition (admitted or discharged) and presented as means with predictive analysis. RESULTS: Between August 2016 and January 2017, the ED evaluated 42,397 adult patients. Of those, 26,976 (64%) were triage level Urgent (3). Of the level 3 patients, 10,279 (38%) received a BIA from a CP. Patients evaluated by a CP were seen approximately 30 mins faster (40% reduction in Door to Doctor time), but stayed 30 mins longer in the ED on average, because the medical decision-making process took >1 hr longer when the patient was initially evaluated by a CP. CONCLUSION: Adapting a concierge medicine model to rapidly evaluate patients resulted in a dramatically reduced Door to Doctor time, but an increase in overall time spent in the ED. This discrepancy was a direct result of the delay in physician disposition.

Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: the Third Sonography Outcomes Assessment Program (SOAP-3) Trial.

CONTEXT: A 2001 Agency for Healthcare Research and Quality Evidence Report on patient safety addressed point-of-care limited ultrasonography guidance for central venous cannulation and strongly recommended real-time, dynamic guidance for all central cannulas. However, on the basis of one limited study, the report dismissed static assistance, a "quick look" with ultrasound to confirm vein location before preparing the sterile field, as unhelpful. OBJECTIVE: The objective of this trial was to compare the overall success rate of central cannula placement with use of dynamic ultrasound (D), static ultrasound (S), and anatomical landmarks (LM). DESIGN AND SETTING: A concealed, randomized, controlled, clinical trial conducted from September 2003 to February 2004 in a U.S. urban teaching hospital. PATIENTS: Two-hundred one patients undergoing internal jugular vein central venous cannulation. INTERVENTIONS: Patients were randomly assigned to three groups: 60 to D, 72 to S, and 69 to LM. An iLook25 SonoSite was used for all imaging. MEASUREMENTS AND MAIN RESULTS: Cannulation success, first-attempt success, and number of attempts were noted. Other measures were vein size and clarity of LM. Results, controlled for pretest difficulty assessment, are stated as odds improvement (95% confidence interval) over LM for D and S. D had an odds 53.5 (6.6-440) times higher for success than LM. S had an odds 3 (1.3-7) times higher for success than LM. The unadjusted success rates were 98%, 82%, and 64% for D, S, and LM. For first-attempt success, D had an odds 5.8 (2.7-13) times higher for first success than LM, and S had an odds 3.4 (1.6-7.2) times higher for first success than LM. The unadjusted first-attempt success rates were 62%, 50%, and 23% for D, S, and LM. CONCLUSIONS: Ultrasound assistance was superior to LM techniques. D outperformed S but may require more training and personnel. All central cannula placement should be conducted with ultrasound assistance. The 2001 Agency for Healthcare Research and Quality Evidence Report dismissing static assistance was incorrect.

Shock index in diagnosing early acute hypovolemia.

OBJECTIVE: The aim of this study was to determine the hemodynamic response and calculated shock index (SI=heart rate [HR]/systolic blood pressure [SBP]) in early acute blood loss. METHODS: This was a prospective observational study that enrolled healthy blood donors. Patients were excluded if not eligible for blood donation. Baseline vital signs were obtained, 450 mL of blood was removed over 20 minutes, and vital signs were repeated immediately postdonation while lying and after 1 and 5 minutes of standing. Difference was tested using a paired t test with P<.01 set for significance. RESULTS: Forty-six patients were enrolled; means for each time interval are shown below with 95% confidence intervals. CONCLUSIONS: A significant elevation in mean SI was observed in healthy volunteers after standing for 1 and 5 minutes. Although significant changes in HR and SBP were observed, these indices were still within "normal" limits. The SI may be more useful in early hemorrhage than either the HR or SBP alone.

Aspects of residency programs' web sites important to student applicants.

OBJECTIVES: To determine which components of a residency Web site (RWS) are important to residency applicants. METHODS: The authors performed a cross-sectional observational study of residency applicants. All applicants were invited to participate and were provided with a nine-question survey. Applicants were asked questions regarding the importance and impact of RWSs on the residency application process. They were also asked to rate items regarding content and aesthetics, and then rank all items in order of importance. Descriptive statistics are reported. Rank-order displays were determined using the Condorcet choice method. RESULTS: One hundred eighty-eight (82%) of the applicants responded to the survey. Seventy-eight percent of the respondents reported that information provided in an RWS influenced their decision to apply to a particular program (41% decided not to apply to at least one program based on the quality of its RWS). Applicants believed that presentation of the residency curriculum was most important. Information about the hospital and its affiliates, faculty and resident information, and research activities followed in the rank order. Least important to applicants were the aesthetic quality of the site, faculty/resident photographs, and educational resource materials. The authors report additional areas of content that applicants thought would be useful to view. CONCLUSIONS: The content, and not necessarily the aesthetic quality, of an RWS is important to residency applicants. The residency program Web site would seem to be an important factor in the applicant's decision to apply. The applicant's perspective provides training program directors and administrators with focused direction in Web site development or for upgrading existing RWSs for use by future applicants.

Delayed diagnosis of small bowel obstruction following laparoscopic lymph node dissection.

Laparoscopic surgical procedures are infrequently complicated by bowel herniation through unsutured trocar sites. Nevertheless, there is a risk of this complication in patients presenting with symptoms of small bowel obstruction after laparoscopy. We present a case of delayed small bowel obstruction due to a Richter's hernia, a rare type of hernia that involves incomplete protrusion of bowel wall through a surgical defect. Knowledge of this potential complication of laparoscopic procedures may prevent the significant morbidity that results from mechanical small bowel obstruction with necrosis.

Shock index in the first trimester of pregnancy and its relationship to ruptured ectopic pregnancy.

UNLABELLED: The shock index (SI), the ratio of heart rate to systolic blood pressure, has been reported to be a useful tool in the evaluation of trauma patients presenting to the emergency department (ED). OBJECTIVES: To determine the range of values for SI seen in first-trimester patients presenting to the ED, and to estimate the ability of the SI to predict ruptured ectopic pregnancy (EP). METHODS: This was a prospective cohort study enrolling all patients in the first trimester of pregnancy presenting to the ED with abdominal pain and/or vaginal bleeding. Patients had a SI calculated based on their presenting vital signs, and were followed longitudinally to determine a final diagnosis. Ectopic pregnancies were categorized based on surgical pathology. Mean levels for SI were determined for each group, and ruptured EPs were compared with all other pregnancies using a receiver operating characteristic (ROC) curve. RESULTS: The study enrolled 280 patients, 24 ruptured EPs, 28 unruptured EPs, and 228 non-EPs. The means for SI were 0.67 (95% CI = 0.65 to 0.68) for non-EPs, 0.64 (95% CI = 0.61 to 0.67) for unruptured EPs, and 0.84 (95% CI = 0.77 to 0.9) for ruptured EPs. The ROC curve for SI, heart rate, mean arterial pressure, and systolic blood pressure demonstrated areas under the curve (AUCs) of 0.84 (95% CI = 0.78 to 0.88), 0.74 (95% CI = 0.67 to 0.79), 0.63 (95% CI = 0.67 to 0.79), and 0.70 (95% CI = 0.64 to 0.77), respectively. CONCLUSIONS: The range of values for SI for patients being evaluated for pain and/or vaginal bleeding within the first trimester of pregnancy, who do not have a ruptured EP, are within the previously reported range of 0.5-0.7 for nonpregnant patients. A SI > 0.85 made the diagnosis of ruptured EP 15.0 (95% CI = 5.6 to 40.4) times more likely. This study suggests that SI could impact directly on the diagnostic and therapeutic course of the patient.