Publications by authors named "Martin Reznek"

24 Publications

  • Page 1 of 1

Financial Implications of Boarding: A Call for Research.

West J Emerg Med 2021 Apr 9;22(3):736-738. Epub 2021 Apr 9.

University of Massachusetts Medical School, Department of Emergency Medicine, Worcester, Massachusetts.

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http://dx.doi.org/10.5811/westjem.2021.1.49527DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8203028PMC
April 2021

A Fast-track Pathway for Emergency General Surgery at an Academic Medical Center.

J Surg Res 2021 Jun 8;267:1-8. Epub 2021 Jun 8.

Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts. Electronic address:

Background: Fast Track Pathways (FTP) directed at reducing length of stay (LOS) and overall costs are being increasingly implemented for emergency surgeries. The purpose of this study is to evaluate implementation of a FTP for Emergency General Surgery (EGS) at an academic medical center (AMC).

Methods: The study included 165 patients at an AMC between 2016 and 2018 who underwent laparoscopic appendectomy (LA), laparoscopic cholecystectomy (LC), or laparoscopic inguinal hernia repair (LI). The FTP group enrolled 89 patients, and 76 controls prior to FTP implementation were evaluated. Time to surgery (TTS), LOS, and post-operative LOS between groups were compared. Direct costs, reimbursements, and patient reported satisfaction (satisfaction 1 = never, 4 = always) were also studied.

Results: The sample was 60.6% female, with a median age of 40 years. Case distribution differed slightly (56.2% versus 42.1% LA, 40.4% versus 57.9% LC, FTP versus control), but TTS was similar between groups (11h39min versus 10h02min, P = 0.633). LOS was significantly shorter in the FTP group (15h17min versus 29h09min, P < 0.001), reflected by shorter post-operative LOS (3h11min versus 20h10min, P< 0.001), fewer patients requiring a hospital bed and overnight stay (P < 0.001). Direct costs were significantly lower in the FTP group, reimbursements were similar (P < 0.001 and P = 0.999 respectively), and average patient reported satisfaction was good (3.3/4).

Conclusion: In an era focused on decreasing cost, optimizing resources, and ensuring patient satisfaction, a FTP can play a significant role in EGS. At an AMC, an EGS FTP significantly decreased LOS, hospital bed utilization while not impacting reimbursement or patient satisfaction.
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http://dx.doi.org/10.1016/j.jss.2021.04.012DOI Listing
June 2021

Operational factors associated with emergency department patient satisfaction: Analysis of the Academy of Administrators of Emergency Medicine/Association of Academic Chairs of Emergency Medicine national survey.

Acad Emerg Med 2021 May 11. Epub 2021 May 11.

Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Patient satisfaction is a focus for emergency department (ED) and hospital administrators. ED patient satisfaction studies have tended to be single site and focused on patient and clinician factors. Inclusion of satisfaction scores in a large, national operations database provided an opportunity to conduct an investigation that included diverse operational factors.

Methods: We performed a retrospective analysis of the 2019 Academy of Administrators in Academic Emergency Medicine/Association of Academic Chairs of Emergency Medicine (AAAEM/AACEM) benchmarking survey to identify associations between operational factors and patient satisfaction. We identified 59 database variables as potential predictors of Press Ganey likelihood-to-recommend and physician overall scores. Using random forest modeling, we identified the top eight predictors in the models and described their associations.

Results: Forty-three (57.3%) academic departments responding to the AAAEM/AACEM survey reported patient satisfaction scores for 78 EDs. Likelihood to recommend ranged from 30.0 to 93.0 (median = 74.8) and was associated with ED length of stay, boarding, use of hallway spaces, hospital annual admissions, faculty base clinical hours, proportion of patients leaving before treatment complete (LBTC), and provider in triage hours per day. Physician overall score ranged from 53.3 to 93.4 (median = 81.9) and was associated with faculty base clinical hours, x-ray utilization, annual ED arrivals, LBTC, use of hallway spaces, arrivals per attending hour, and CT utilization.

Conclusions: ED patient satisfaction was associated with intrinsic and extrinsic factors, some being potentially manageable within the ED but others being relatively fixed or outside the control of ED operations. For likelihood to recommend, patient flow was dominant, with erosion of satisfaction observed with increased boarding and longer LOS. Factors associated with physician overall score were more varied. The use of hallway spaces and base clinical hours greater than 1,500 per year were associated with both lower likelihood-to-recommend and lower physician overall scores.
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http://dx.doi.org/10.1111/acem.14278DOI Listing
May 2021

2017 AAAEM Benchmarking Survey: Comparing Pediatric and Adult Academic Emergency Departments.

Pediatr Emerg Care 2020 Jan 21. Epub 2020 Jan 21.

Johns Hopkins Medicine, Baltimore, MD.

Objectives: The Academy of Administrators in Academic Emergency Medicine Benchmark Survey of academic emergency departments (EDs) was conducted in 2017. We compared operational measures between pediatric and adult (defined as fewer than 5% pediatric visits) EDs based on survey data. Emergency departments in dedicated pediatric hospitals were not represented.

Methods: Measures included: (1) patient volumes, length of stay, and acuity; and 2) faculty staffing, productivity, and percent effort in academics. t Tests were used to compare continuous measures and inferences for categorical variables were made using Pearson χ test.

Results: The analysis included 17 pediatric and 52 adult EDs. We found a difference in the number of annual visits between adult (median, 66,275; interquartile range [IQR], 56,184-77,702) and pediatric EDs (median, 25,416; IQR, 19,840-29,349) (P < 0.0001). Mean "arrivals per faculty clinical hour" and "total arrivals per treatment space" showed no differences. The proportion of visits (1) arriving by emergency medical services and (2) for behavioral health were significantly higher in adult EDs (both P < 0.0001). The mean length of stay in hours for "all" patients was significantly longer in adult (5.4; IQR, 5.0-6.6) than in pediatric EDs (3.5; IQR, 2.9-4.3; P = 0.017). A similar difference was found for "discharged" patients (P = 0.004). Emergency severity indices, professional evaluation and management codes, and hospitalization rates all suggest higher acuity in adult EDs (all P < 0.0001). There were no differences in mean work relative value units per patient or in the distribution of full time equivalent effort dedicated to academics.

Conclusions: In this cohort, significant differences in operational measures exist between academic adult and pediatric EDs. No differences were found when considering per unit measures, such as arrivals per faculty clinical hour or per treatment space.
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http://dx.doi.org/10.1097/PEC.0000000000002002DOI Listing
January 2020

Clinical operations of academic versus non-academic emergency departments: a descriptive comparison of two large emergency department operations surveys.

BMC Emerg Med 2019 11 21;19(1):72. Epub 2019 Nov 21.

Department of Emergency Medicine, Wright State University Boonshoft School of Medicin Dayton Ohio USA and US Acute Care Solutions, Canton, OH, USA.

Background: Academic and non-academic emergency departments (EDs) are regularly compared in clinical operations benchmarking despite suggestion that the two groups may differ in their clinical operations characteristics. and outcomes. We sought to describe and compare clinical operations characteristics of academic versus non-academic EDs.

Methods: We performed a descriptive, comparative analysis of academic and non-academic adult and general EDs with 40,000+ annual encounters, using the Academy of Academic Administrators of Emergency Medicine (AAAEM)/Association of Academic Chairs of Emergency Medicine (AACEM) and Emergency Department Benchmarking Alliance (EDBA) survey results. We defined academic EDs as primary teaching sites for emergency medicine (EM) residencies and non-academic EDs as sites with minimal resident involvement. We constructed the academic and non-academic cohorts from the AAAEM/AACEM and EDBA surveys, respectively, and analyzed metrics common to both surveys.

Results: Eighty and 454 EDs met inclusion criteria for academic and non-academic EDs, respectively. Academic EDs had more median annual patient encounters (73,001 vs 54,393), lower median proportion of pediatric patients (6.3% vs 14.5%), higher median proportion of EMS patients (27% vs 19%), and were more commonly designated as Level I or II Trauma Centers (94% vs 24%). Median patient arrival-to-provider times did not differ (26 vs 25 min). Median length-of-stay was longer (277 vs 190 min) for academic EDs, and left-before-treatment-complete was higher (5.7% vs 2.9%). MRI utilization was higher for academic EDs (2.2% patients with at least one MRI vs 1.0 MRIs performed per 100 patients). Patients-per-hour of provider coverage was lower for academic EDs with and without consideration for advanced practice providers and residents.

Conclusions: Demographic and operational performance measures differ between academic and non-academic EDs, suggesting that the two groups may be inappropriate operational performance comparators. Causes for the differences remain unclear but the differences appear not to be attributed solely to the academic mission.
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http://dx.doi.org/10.1186/s12873-019-0285-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868754PMC
November 2019

Delayed Recognition of Acute Stroke by Emergency Department Staff Following Failure to Activate Stroke by Emergency Medical Services.

West J Emerg Med 2019 Mar 6;20(2):342-350. Epub 2019 Feb 6.

University of Massachusetts School of Medicine, Department of Emergency Medicine, Worcester, Massachusetts.

Introduction: Early recognition and pre-notification by emergency medical services (EMS) improves the timeliness of emergency department (ED) stroke care; however, little is known regarding the effects on care should EMS providers fail to pre-notify. We sought to determine if potential stroke patients transported by EMS, but for whom EMS did not provide pre-notification, suffer delays in ED door-to-stroke-team activation (DTA) as compared to the other available cohort of patients for whom the ED is not pre-notified-those arriving by private vehicle.

Methods: We queried our prospective stroke registry to identify consecutive stroke team activation patients over 12 months and retrospectively reviewed the electronic health record for each patient to validate registry data and abstract other clinical and operational data. We compared patients arriving by private vehicle to those arriving by EMS without pre-notification, and we employed a multivariable, penalized regression model to assess the probability of meeting the national DTA goal of ≤15 minutes, controlling for a variety of clinical factors.

Results: Our inclusion criteria were met by 200 patients. Overall performance of the regression model was excellent (area under the curve 0.929). Arrival via EMS without pre-notification, compared to arrival by private vehicle, was associated with an adjusted risk ratio of 0.55 (95% confidence interval, 0.27-0.96) for achieving DTA ≤ 15 minutes.

Conclusion: Our single-center data demonstrate that potential stroke patients arriving via EMS without pre-notification are less likely to meet the national DTA goal than patients arriving via other means. These data suggest a negative, unintended consequence of otherwise highly successful EMS efforts to improve stroke care, the root of which may be ED staff over-reliance on EMS for stroke recognition.
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http://dx.doi.org/10.5811/westjem.2018.12.40577DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404724PMC
March 2019

Code Help: Can This Unique State Regulatory Intervention Improve Emergency Department Crowding?

West J Emerg Med 2018 May 8;19(3):501-509. Epub 2018 Mar 8.

University of Massachusetts Medical School, Department of Emergency Medicine, Worcester, Massachusetts.

Introduction: Emergency department (ED) crowding adversely affects multiple facets of high-quality care. The Commonwealth of Massachusetts mandates specific, hospital action plans to reduce ED boarding via a mechanism termed "Code Help." Because implementation appears inconsistent even when hospital conditions should have triggered its activation, we hypothesized that compliance with the Code Help policy would be associated with reduction in ED boarding time and total ED length of stay (LOS) for admitted patients, compared to patients seen when the Code Help policy was not followed.

Methods: This was a retrospective analysis of data collected from electronic, patient-care, timestamp events and from a prospective Code Help registry for consecutive adult patients admitted from the ED at a single academic center during a 15-month period. For each patient, we determined whether the concurrent hospital status complied with the Code Help policy or violated it at the time of admission decision. We then compared ED boarding time and overall ED LOS for patients cared for during periods of Code Help policy compliance and during periods of Code Help policy violation, both with reference to patients cared for during normal operations.

Results: Of 89,587 adult patients who presented to the ED during the study period, 24,017 (26.8%) were admitted to an acute care or critical care bed. Boarding time ranged from zero to 67 hours 30 minutes (median 4 hours 31 minutes). Total ED LOS for admitted patients ranged from 11 minutes to 85 hours 25 minutes (median nine hours). Patients admitted during periods of Code Help policy violation experienced significantly longer boarding times (median 20 minutes longer) and total ED LOS (median 46 minutes longer), compared to patients admitted under normal operations. However, patients admitted during Code Help policy compliance did not experience a significant increase in either metric, compared to normal operations.

Conclusion: In this single-center experience, implementation of the Massachusetts Code Help regulation was associated with reduced ED boarding time and ED LOS when the policy was consistently followed, but there were adverse effects on both metrics during violations of the policy.
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http://dx.doi.org/10.5811/westjem.2018.1.36641DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5942017PMC
May 2018

Mortality Associated With Emergency Department Boarding Exposure: Are There Differences Between Patients Admitted to ICU and Non-ICU Settings?

Med Care 2018 05;56(5):436-440

Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.

Background: Emergency Department (ED) boarding threatens patient safety. It is unclear whether boarding differentially affects patients admitted to intensive care units (ICUs) versus non-ICU settings.

Research Design And Subjects: We performed a 2-hospital, 18-month, cross-sectional, observational, descriptive study of adult patients admitted from the ED. We used Kaplan-Meier estimation and Cox Proportional Hazards regression to describe differences in boarding time among patients who died during hospitalization versus those who survived, controlling for covariates that could affect mortality risk or boarding exposure, and separately evaluating patients admitted to ICUs versus non-ICU settings.

Measures: We extracted age, race, sex, time variables, admission unit, hospital disposition, and Elixhauser comorbidity measures and calculated boarding time for each admitted patient.

Results: Among 39,781 admissions from the EDs (21.3% to ICUs), non-ICU patients who died in-hospital had a 1.2-fold risk (95% confidence interval, 1.03-1.36; P=0.016) of having experienced longer boarding times than survivors, accounting for covariates. We did not observe a difference among patients admitted to ICUs.

Conclusions: Among non-ICU patients, those who died during hospitalization were more likely to have had incrementally longer boarding exposure than those who survived. This difference was not observed for ICU patients. Boarding risk mitigation strategies focused on ICU patients may have accounted for this difference, but we caution against interpreting that boarding can be safe. Segmentation by patients admitted to ICU versus non-ICU settings in boarding research may be valuable in ensuring that the safety of both groups is considered in hospital flow and boarding care improvements.
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http://dx.doi.org/10.1097/MLR.0000000000000902DOI Listing
May 2018

Effect of a Data-driven Intervention on Opioid Prescribing Intensity Among Emergency Department Providers: A Randomized Controlled Trial.

Acad Emerg Med 2018 05 2;25(5):482-493. Epub 2018 Apr 2.

Department of Emergency Medicine, Worcester, MA.

Objective: Little is known about accuracy of provider self-perception of opioid prescribing. We hypothesized that an intervention asking emergency department (ED) providers to self-identify their opioid prescribing practices compared to group norms-and subsequently providing them with their actual prescribing data-would alter future prescribing compared to controls.

Methods: This was a prospective, multicenter randomized trial in which all attending physicians, residents, and advanced practice providers at four EDs were randomly assigned either to no intervention or to a brief data-driven intervention during which providers were: 1) asked to self-identify and explicitly report to research staff their perceived opioid prescribing in comparison to their peers and 2) then given their actual data with peer group norms for comparison. Our primary outcome was the change in each provider's proportion of patients discharged with an opioid prescription at 6 and 12 months. Secondary outcomes were opioid prescriptions per hundred total prescriptions and normalized morphine milligram equivalents prescribed. Our primary comparison stratified intervention providers by those who underestimated their prescribing and those who did not underestimate their prescribing, both compared to controls.

Results: Among 109 total participants, 51 were randomized to the intervention, 65% of whom underestimated their opioid prescribing. Intervention participants who underestimated their baseline prescribing had larger-magnitude decreases than controls (Hodges-Lehmann difference = -2.1 prescriptions per hundred patients at 6 months [95% confidence interval {CI} = -3.9 to -0.5] and -2.2 per hundred at 12 months [95% CI = -4.8 to -0.01]). Intervention participants who did not underestimate their prescribing had similar changes to controls.

Conclusions: Self-perception of prescribing was frequently inaccurate. Providing clinicians with their actual opioid prescribing data after querying their self-perception reduced future prescribing among providers who underestimated their baseline prescribing. Our findings suggest that guideline and policy interventions should directly address the potential barrier of inaccurate provider self-awareness.
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http://dx.doi.org/10.1111/acem.13400DOI Listing
May 2018

System-Level Process Change Improves Communication and Follow-Up for Emergency Department Patients With Incidental Radiology Findings.

J Am Coll Radiol 2018 Apr 3;15(4):639-647. Epub 2018 Jan 3.

UMass Memorial Medical Center and University of Massachusetts Medical School, Worcester, Massachusetts.

The appropriate communication and management of incidental findings on emergency department (ED) radiology studies is an important component of patient safety. Guidelines have been issued by the ACR and other medical associations that best define incidental findings across various modalities and imaging studies. However, there are few examples of health care facilities designing ways to manage incidental findings. Our institution aimed to improve communication and follow-up of incidental radiology findings in ED patients through the collaborative development and implementation of system-level process changes including a standardized loop-closure method. We assembled a multidisciplinary team to address the nature of these incidental findings and designed new workflows and operational pathways for both radiology and ED staff to properly communicate incidental findings. Our results are based on all incidental findings received and acknowledged between November 1, 2016, and May 30, 2017. The total number of incidental findings discovered was 1,409. Our systematic compliance fluctuated between 45% and 95% initially after implementation. However, after overcoming various challenges through optimization, our system reached a compliance rate of 93% to 95%. Through the implementation of our new, standardized communication system, a high degree of compliance with loop closure for ED incidental radiology findings was achieved at our institution.
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http://dx.doi.org/10.1016/j.jacr.2017.11.031DOI Listing
April 2018

Contributions of Academic Emergency Medicine Programs to U.S. Health Care: Summary of the AAAEM-AACEM Benchmarking Data.

Acad Emerg Med 2018 04 13;25(4):444-452. Epub 2017 Nov 13.

Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA.

Objectives: The societal contribution of emergency care in the United States has been described. The role and impact of academic emergency departments (EDs) has been less clear. Our report summarizes the results of a benchmarking effort specifically focused on academic emergency medicine (EM) practices.

Methods: From October through December 2016, the Academy of Academic Administrators of Emergency Medicine (AAAEM) and the Association of Academic Chairs of Emergency Medicine (AACEM) jointly administered a benchmarking survey to allopathic, academic departments and divisions of emergency medicine. Participation was voluntary and nonanonymous. The survey queried various aspects of the three components of the tripartite academic mission: clinical care, education and research, and faculty effort and compensation. Responses reflected a calendar year from July 1, 2015, to June 30, 2016.

Results: Of 107 eligible U.S. allopathic, academic departments and divisions of emergency medicine, 79 (74%) responded to the survey overall, although individual questions were not always answered by all responding programs. The 79 responding programs reported 6,876,189 patient visits at 97 primary and affiliated academic clinical sites. A number of clinical operations metrics related to the care of these patients at these sites are reported in this study. All responding programs had active educational programs for EM residents, with a median of 37 residents per program. Nearly half of the overall respondents reported responsibility for teaching medical students in mandatory EM clerkships. Fifty-two programs reported research and publication activity, with a total of $129,494,676 of grant funding and 3,059 publications. Median faculty effort distribution was clinical effort, 66.9%; education effort, 12.7%; administrative effort, 12.0%; and research effort, 6.9%. Median faculty salary was $277,045.

Conclusions: Academic EM programs are characterized by significant productivity in clinical operations, education, and research. The survey results reported in this investigation provide appropriate benchmarking for academic EM programs because they allow for comparison of academic programs to each other, rather than nonacademic programs that do not necessarily share the additional missions of research and education and may have dissimilar working environments.
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http://dx.doi.org/10.1111/acem.13337DOI Listing
April 2018

A Queue-Based Monte Carlo Analysis to Support Decision Making for Implementation of an Emergency Department Fast Track.

J Healthc Eng 2017 28;2017:6536523. Epub 2017 Mar 28.

Department of Emergency Medicine, University of Massachusetts Medical School and UMass Memorial Health Care, Worcester, MA 01655, USA.

Emergency departments (EDs) are seeking ways to utilize existing resources more efficiently as they face rising numbers of patient visits. This study explored the impact on patient wait times and nursing resource demand from the addition of a fast track, or separate unit for low-acuity patients, in the ED using a queue-based Monte Carlo simulation in MATLAB. The model integrated principles of queueing theory and expanded the discrete event simulation to account for time-based arrival rates. Additionally, the ED occupancy and nursing resource demand were modeled and analyzed using the Emergency Severity Index (ESI) levels of patients, rather than the number of beds in the department. Simulation results indicated that the addition of a separate fast track with an additional nurse reduced overall median wait times by 35.8 ± 2.2 percent and reduced average nursing resource demand in the main ED during hours of operation. This novel modeling approach may be easily disseminated and informs hospital decision-makers of the impact of implementing a fast track or similar system on both patient wait times and acuity-based nursing resource demand.
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http://dx.doi.org/10.1155/2017/6536523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5387845PMC
July 2019

Door-to-Imaging Time for Acute Stroke Patients Is Adversely Affected by Emergency Department Crowding.

Stroke 2017 Jan 17;48(1):49-54. Epub 2016 Nov 17.

From the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA (M.A.R, E.M., S.S.M., M.N.Y); and CVS Health, Woonsocket, RI (N.T.D.).

Background And Purpose: National guidelines call for door-to-imaging time (DIT) within 25 minutes for suspected acute stroke patients. Studies examining factors that affect DIT have focused primarily on stroke-specific care processes and patient-specific factors. We hypothesized that emergency department (ED) crowding is associated with longer DIT.

Methods: We conducted a retrospective investigation of 1 year of consecutive patients in our prospective Code Stroke registry, which included all ED stroke team activations. The registry and electronic health records were abstracted for 27 potential predictors of DIT, including patient, stroke care process, and ED operational factors. We fit a multivariate logistic regression model and calculated odds ratios and 95% confidence intervals. Second, we constructed a random forest recursive partitioning model to cross-validate our findings and explore the proportional importance of each category of predictor. Our primary outcome was the binary variable of DIT within the 25-minute goal.

Results: A total of 463 patients met inclusion criteria. In the regression model, ED occupancy rate emerged as a predictor of DIT, with odds ratio of 0.83 (95% confidence interval, 0.75-0.91) of DIT within 25 minutes per 10% absolute increase in ED occupancy rate. The secondary analysis estimated that ED operational factors accounted for nearly 14% of the algorithm's prediction of DIT.

Conclusions: ED crowding is associated with reduced odds of meeting DIT goals for acute stroke. In addition to improving stroke-specific processes of care, efforts to reduce ED overcrowding should be considered central to optimizing the timeliness of acute stroke care.
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http://dx.doi.org/10.1161/STROKEAHA.116.015131DOI Listing
January 2017

Electronic control device prongs: a growing cause of bloodborne pathogen exposure?

Am J Infect Control 2015 Dec;43(12):1373-4

Microbiology and Physiological Systems, Division of Infectious Diseases, UMass Memorial Medical Center, Worcester, MA.

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http://dx.doi.org/10.1016/j.ajic.2015.07.015DOI Listing
December 2015

Patient safety incident capture resulting from incident reports: a comparative observational analysis.

BMC Emerg Med 2015 Apr 11;15. Epub 2015 Apr 11.

Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.

Background: Patient safety incident (PSI) discovery is an essential component of quality improvement. When submitted, incident reports may provide valuable opportunities for PSI discovery. However, little objective information is available to date to quantify or demonstrate this value. The objective of this investigation was to assess how often Emergency Department (ED) incident reports submitted by different sources led to the discovery of PSIs.

Methods: A standardized peer review process was implemented to evaluate all incident reports submitted to the ED. Findings of the peer review analysis were recorded prospectively in a quality improvement database. A retrospective analysis of the quality improvement database was performed to calculate the PSI capture rates for incident reports submitted by different source groups.

Results: 363 incident reports were analyzed over a period of 18 months; 211 were submitted by healthcare providers (HCPs) and 126 by non-HCPs. PSIs were identified in 108 resulting in an overall capture rate of 31%. HCP-generated reports resulted in a 44% capture rate compared to 10% for non-HCPs (p < 0.001). There was no difference in PSI capture between sub-groups of HCPs and non-HCPs.

Conclusion: HCP-generated ED incident reports were much more likely to capture PSIs than reports submitted by non-HCPs. However, HCP reports still led to PSI discovery less than half the time. Further research is warranted to develop effective strategies to improve the utility of incident reports from both HCPs and non-HCPs.
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http://dx.doi.org/10.1186/s12873-015-0032-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4404244PMC
April 2015

Emergency department patient safety incident characterization: an observational analysis of the findings of a standardized peer review process.

BMC Emerg Med 2014 Aug 8;14:20. Epub 2014 Aug 8.

Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA.

Background: Emergency Department (ED) care has been reported to be prone to patient safety incidents (PSIs). Improving our understanding of PSIs is essential to prevent them. A standardized, peer review process was implemented to identify and analyze ED PSIs. The primary objective of this investigation was to characterize ED PSIs identified by the peer review process. A secondary objective was to characterize PSIs that led to patient harm. In addition, we sought to provide a detailed description of the peer review process for others to consider as they conduct their own quality improvement initiatives.

Methods: An observational study was conducted in a large, urban, tertiary-care ED. Over a two-year period, all ED incident reports were investigated via a standardized, peer review process. PSIs were identified and analyzed for contributing factors including systems failures and practitioner-based errors. The classification system for factors contributing to PSIs was developed based on systems previously reported in the emergency medicine literature as well as the investigators' experience in quality improvement and peer review. All cases in which a PSI was discovered were further adjudicated to determine if patient harm resulted.

Results: In 24 months, 469 cases were investigated, identifying 152 PSIs. In total, 188 systems failures and 96 practitioner-based errors were found to have contributed to the PSIs. In twelve cases, patient harm was determined to have resulted from PSIs. Systems failures were identified in eleven of the twelve cases in which a PSI resulted in patient harm.

Conclusion: Systems failures were almost twice as likely as practitioner-based errors to contribute to PSIs, and systems failures were present in the majority of cases resulting in patient harm. To effectively reduce PSIs, ED quality improvement initiatives should focus on systems failure reduction.
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http://dx.doi.org/10.1186/1471-227X-14-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4132274PMC
August 2014

Improved incident reporting following the implementation of a standardized emergency department peer review process.

Int J Qual Health Care 2014 Jun 25;26(3):278-86. Epub 2014 Apr 25.

Department of Emergency Medicine (MAR) and Department of Quantitative Health Sciences (BAB), University of Massachusetts Medical School, 55 Lake Avenue, Worcester, MA 01655, USA.

Objective: Incident reporting is an important component of health care quality improvement. The objective of this investigation was to evaluate the effectiveness of an emergency department (ED) peer review process in promoting incident reporting.

Design: An observational, interrupted time-series analysis of health care provider (HCP) incident reporting to the ED during a 30-month study period prior to and following the peer review process implementation and a survey-based assessment of physician perceptions of the peer review process' educational value and its effectiveness in identifying errors.

Setting: Large, urban, academic ED.

Participants And Interventions: HCPs were invited to participate in a standardized, non-punitive, non-anonymous peer review process that involved analysis and structured discussion of incident reports submitted to ED physician leadership.

Main Outcome Measures: Monthly frequency of incident reporting by HCPs and physician perceptions of the peer review process.

Results: HCPs submitted 314 incident reports to the ED over the study period. Following the intervention, frequency of reporting by HCPs within the hospital increased over time. The frequencies of self-reporting, reporting by other ED practitioners and reporting by non-ED practitioners within the hospital increased compared with a control group of outside HCPs (P = 0.0019, P = 0.0025 and P < 0.0001). Physicians perceived the peer review process to be educational and highly effective in identifying errors.

Conclusions: The implementation of a non-punitive peer review process that provides timely feedback and is perceived as being valuable for error identification and education can lead to increased incident reporting by HCPs.
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http://dx.doi.org/10.1093/intqhc/mzu045DOI Listing
June 2014

Quality Education and Safe Systems Training (QuESST): Development and Assessment of a Comprehensive Cross-Disciplinary Resident Quality and Patient Safety Curriculum.

J Grad Med Educ 2010 Jun;2(2):222-7

Background: Over the past decade, regulatory bodies have heightened their emphasis on health care quality and safety. Education of physicians is a priority in this effort, with the Accreditation Council for Graduate Medical Education requiring that trainees attain competence in practice-based learning and improvement and systems-based practice. To date, several studies about the use of resident education related to quality and safety have been published, but no comprehensive interdisciplinary curricula seem to exist. Effective, formal, comprehensive cross-disciplinary resident training in quality and patient safety appear to be a vital need.

Methods: To address the need for comprehensive resident training in quality and patient safety, we developed and assessed a formal standardized cross-disciplinary curriculum entitled Quality Education and Safe Systems Training (QuESST). The curriculum was offered to first-year residents in a large urban medical center. Preintervention and postintervention assessments and participant perception surveys evaluated the effectiveness and educational value of QuESST.

Results: A total of 138 first-year medical and pharmacy residents participated in the QuESST course. Paired analysis of preintervention and postintervention assessments showed significant improvement in participants' knowledge of quality and patient safety. Participants' perceptions about the value of the curriculum were favorable, as evidenced by a mean response of 1.8 on a scale of 1 (strongly agree) to 5 (strongly disagree) that the course should be taught to subsequent residency classes.

Conclusion: QuESST is an effective comprehensive quality curriculum for residents. Based on these findings, our institution has made QuESST mandatory for all future first-year resident cohorts. Other institutions should explore the value of QuESST or a similar curriculum for enhancing resident competence in quality and patient safety.
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http://dx.doi.org/10.4300/JGME-D-10-00028.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2941382PMC
June 2010

Developing expert medical teams: toward an evidence-based approach.

Acad Emerg Med 2008 Nov;15(11):1025-36

Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA.

Current health care literature cites communication breakdown and teamwork failures as primary threats to patient safety. The unique, dynamic environment of the emergency department (ED) and the complexity of patient care necessitate the development of strong interdisciplinary team skills among emergency personnel. As part of the 2008 Academic Emergency Medicine Consensus Conference on "The Science of Simulation in Healthcare," our workshop group identified key theory and evidence-based recommendations for the design and implementation of team training programs. The authors then conducted an extensive review of the team training literature within the domains of organizational psychology, aviation, military, management, and health care. This review, in combination with the workshop session, formed the basis for recommendations and need for further research in six key areas: 1) developing and refining core competencies for emergency medicine (EM) teams; 2) leadership training for emergency physicians (EPs); 3) conducting comprehensive needs analyses at the organizational, personnel, and task levels; 4) development of training platforms to maximize knowledge transfer; 5) debriefing and provision of feedback; and 6) proper implementation of simulation technology. The authors believe that these six areas should form an EM team training research platform to advance the EM literature, while leveraging the unique team structures present in EM to expand team training theory and research.
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http://dx.doi.org/10.1111/j.1553-2712.2008.00232.xDOI Listing
November 2008

The use of simulation in emergency medicine: a research agenda.

Acad Emerg Med 2007 Apr 15;14(4):353-63. Epub 2007 Feb 15.

Department of Emergency Medicine, Lehigh Valley Hospital and Health Network Affiliated with Pennsylvania State University School of Medicine, Allentown, PA, USA.

Medical simulation is a rapidly expanding area within medical education. In 2005, the Society for Academic Emergency Medicine Simulation Task Force was created to ensure that the Society and its members had adequate access to information and resources regarding this new and important topic. One of the objectives of the task force was to create a research agenda for the use of simulation in emergency medical education. The authors present here the consensus document from the task force regarding suggested areas for research. These include opportunities to study reflective experiential learning, behavioral and team training, procedural simulation, computer screen-based simulation, the use of simulation for evaluation and testing, and special topics in emergency medicine. The challenges of research in the field of simulation are discussed, including the impact of simulation on patient safety. Outcomes-based research and multicenter efforts will serve to advance simulation techniques and encourage their adoption.
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http://dx.doi.org/10.1197/j.aem.2006.11.021DOI Listing
April 2007

See one, do one, teach one: advanced technology in medical education.

Acad Emerg Med 2004 Nov;11(11):1149-54

Evanston-Northwestern Health Care Center for Simulation Technology Academics and Research, Division of Emergency Medicine, 2650 Ridge Avenue, Evanston, IL 60201, USA.

Unlabelled: The concept of "learning by doing" has become less acceptable, particularly when invasive procedures and high-risk care are required. Restrictions on medical educators have prompted them to seek alternative methods to teach medical knowledge and gain procedural experience. Fortunately, the last decade has seen an explosion of the number of tools available to enhance medical education: web-based education, virtual reality, and high fidelity patient simulation. This paper presents some of the consensus statements in regard to these tools agreed upon by members of the Educational Technology Section of the 2004 AEM Consensus Conference for Informatics and Technology in Emergency Department Health Care, held in Orlando, Florida.

Findings: Web-based teaching: 1) Every ED should have access to medical educational materials via the Internet, computer-based training, and other effective education methods for point-of-service information, continuing medical education, and training. 2) Real-time automated tools should be integrated into Emergency Department Information Systems [EDIS] for contemporaneous education. Virtual reality [VR]: 1) Emergency physicians and emergency medicine societies should become more involved in VR development and assessment. 2) Nationally accepted protocols for the proper assessment of VR applications should be adopted and large multi-center groups should be formed to perform these studies. High-fidelity simulation: Emergency medicine residency programs should consider the use of high-fidelity patient simulators to enhance the teaching and evaluation of core competencies among trainees.

Conclusions: Across specialties, patient simulation, virtual reality, and the Web will soon enable medical students and residents to... see one, simulate many, do one competently, and teach everyone.
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http://dx.doi.org/10.1197/j.aem.2004.08.003DOI Listing
November 2004

Emergency medicine crisis resource management (EMCRM): pilot study of a simulation-based crisis management course for emergency medicine.

Acad Emerg Med 2003 Apr;10(4):386-9

Center for Advanced Technology in Surgery at Stanford, Stanford University School of Medicine, Stanford, CA, USA.

Objectives: To determine participant perceptions of Emergency Medicine Crisis Resource Management (EMCRM), a simulation-based crisis management course for emergency medicine.

Methods: EMCRM was created using Anesthesia Crisis Resource Management (ACRM) as a template. Thirteen residents participated in one of three pilot courses of EMCRM; following a didactic session on principles of human error and crisis management, the residents participated in simulated emergency department crisis scenarios and instructor-facilitated debriefing. The crisis simulations involved a computer-enhanced mannequin simulator and standardized patients. After finishing the course, study subjects completed a horizontal numerical scale survey (1 = worst rating to 5 = best rating) of their perceptions of EMCRM. Descriptive statistics were calculated to evaluate the data.

Results: The study subjects found EMCRM to be enjoyable (4.9 +/- 0.3) (mean +/- SD) and reported that the knowledge gained from the course would be helpful in their practices (4.5 +/- 0.6). The subjects believed that the simulation environment prompted realistic responses (4.6 +/- 0.8) and that the scenarios were highly believable (4.8 +/- 0.4). The participants reported that EMCRM was best suited for residents (4.9 +/- 0.3) but could also benefit students and attending physicians. The subjects believed that the course should be repeated every 8.2 +/- 3.3 months.

Conclusions: The EMCRM participants rated the course very favorably and believed that the knowledge gained would be beneficial in their practices. The extremely positive response to EMCRM found in this pilot study suggests that this training modality may be valuable in training emergency medicine residents.
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http://dx.doi.org/10.1111/j.1553-2712.2003.tb01354.xDOI Listing
April 2003

Evaluation of the educational effectiveness of a virtual reality intravenous insertion simulator.

Acad Emerg Med 2002 Nov;9(11):1319-25

Center for Advanced Technology in Surgery at Stanford, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.

Objective: To evaluate construct and content validity as well as learners' perceptions of CathSim, a virtual reality intravenous (IV) insertion simulator.

Methods: A prospective cohort study design was employed to determine construct validity, and a participant survey was used to ascertain content validity as well as user perceptions of CathSim. Forty-one attendings, residents, and medical students in emergency medicine and anesthesia attempted five simulated IV insertions on CathSim. Subject performances were scored by the computer, and subject perceptions of the simulator were measured using a Likert scale questionnaire (1 = worst rating; 5 = best rating). The subjects were divided into three groups (novices, intermediates, and experts) based on previous IV experience. To determine construct validity, performances of the three groups were compared using one-way analysis of variance (ANOVA). To determine content validity, the experts' perceptions of the simulator's realism and usefulness were assessed. Study subjects' perceptions of the simulator's ease of use and overall appeal were analyzed.

Results: The experts scored better than the others in five of nine scoring parameters (p < 0.05). The experts rated the realism of CathSim's four major simulation components at 3.85, 3.46, 3.69, and 3.46; the overall realism of CathSim at 2.93; and its utility for medical student training at 4.57. The simulator's ease of use was rated at 2.34 by all subjects. Novices reported a score of 4.59 regarding their likelihood to use the simulator.

Conclusions: CathSim demonstrated construct validity in five of nine internal scoring parameters and was judged to be adequately realistic and highly useful for medical student training. Despite being difficult to learn to use, it remained appealing to the users, especially the novices.
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http://dx.doi.org/10.1111/j.1553-2712.2002.tb01594.xDOI Listing
November 2002

Virtual reality and simulation: training the future emergency physician.

Acad Emerg Med 2002 Jan;9(1):78-87

Division of Emergency Medicine, Department of Surgery, Center for Advanced Technology in Surgery at Stanford, Stanford University Medical Center, Stanford, CA, USA.

The traditional system of clinical education in emergency medicine relies on practicing diagnostic, therapeutic, and procedural skills on live patients. The ethical, financial, and practical weaknesses of this system are well recognized, but the alternatives that have been explored to date have shown even greater flaws. However, ongoing progress in the area of virtual reality and computer-enhanced simulation is now providing educational applications that show tremendous promise in overcoming most of the deficiencies associated with live-patient training. It will be important for academic emergency physicians to become more involved with this technology to ensure that our educational system benefits optimally.
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http://dx.doi.org/10.1111/j.1553-2712.2002.tb01172.xDOI Listing
January 2002