Publications by authors named "Michael Redlener"

9 Publications

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Deploying a novel custom mobile application for STEMI activation and transfer in a large healthcare system to improve cross-team workflow. STEMIcathAID implementation project.

Am Heart J 2022 Jun 30;253:30-38. Epub 2022 Jun 30.

The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address:

Background: ST-segment elevation myocardial infarction (STEMI) is a high-risk patient medical emergency. We developed a secure mobile application, STEMIcathAID, to optimize care for STEMI patients by providing a digital platform for communication between the STEMI care team members, EKG transmission, cardiac catherization laboratory (cath lab) activation and ambulance tracking. The aim of this report is to describe the implementation of the app into the current STEMI workflow in preparation for a pilot project employing the app for inter-hospital STEMI transfer.

Approach: App deployment involved key leadership stakeholders from all multidisciplinary teams taking care of STEMI patients. The team developed a transition plan addressing all aspects of the health system improvement process including the workflow analysis and redesign, app installation, personnel training including user account access to the app, and development of a quality assurance program for progress evaluation. The pilot will go live in the Emergency Department (ED) of one of the hospitals within the Mount Sinai Hospital System (MSHS) during the daytime weekday hours at the beginning and extending to 24/7 schedule over 4-6 weeks. For the duration of the pilot, ED personnel will combine the STEMIcathAID app activation with previous established STEMI activation processes through the MSHS Clinical Command Center (CCC) to ensure efficient and reliable response to a STEMI alert. More than 250 people were provisioned app accounts including ED Physicians and frontline nurses, and trained on their user-specific roles and responsibilities and scheduled in the app. The team will be provided with a feedback form that is discipline specific to complete after every STEMI case in order to collect information on user experience with the STEMIcathAID app functionality. The form will also provide quantitative metrics for the key time sensitive steps in STEMI care.

Conclusions: We developed a uniform approach for deployment of a mobile application for STEMI activation and transfer in a large urban healthcare system to optimize the clinical workflow in STEMI care. The results of the pilot will demonstrate whether the app has a significant impact on the quality of care for transfer of STEMI patients.
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http://dx.doi.org/10.1016/j.ahj.2022.06.008DOI Listing
June 2022

Quality Management of Prehospital Airway Programs: An NAEMSP Position Statement and Resource Document.

Prehosp Emerg Care 2022 ;26(sup1):14-22

Prehospital airway management encompasses a multitude of complex decision-making processes, techniques, and interventions. Quality management (encompassing quality assurance and quality improvement activities) in EMS is dynamic, evidence-based, and most of all, patient-centric. Long a mainstay of the EMS clinician skillset, airway management deserves specific focus and attention and dedicated quality management processes to ensure the delivery of high-quality clinical care.It is the position of NAEMSP that:All EMS agencies should dedicate sufficient resources to patient-centric, comprehensive prehospital airway quality management program. These quality management programs should consist of prospective, concurrent, and retrospective activities. Quality management programs should be developed and operated with the close involvement of the medical director.Quality improvement and quality assurance efforts should operate in an educational, non-disciplinary, non-punitive, evidence-based medicine culture focused on patient safety. The highest quality of care is only achieved when the quality management program rewards those who identify and seek to prevent errors before they occur.Information evaluated in prehospital airway quality management programs should include both subjective and objective data elements with uniform reporting and operational definitions.EMS systems should regularly measure and report process, outcome, and balancing airway management measures.Quality management activities require large-scale bidirectional information sharing between EMS agencies and receiving facilities. Hospital outcome information should be shared with agencies and the involved EMS clinicians.Findings from quality management programs should be used to guide and develop initial education and continued training.Quality improvement programs must continually undergo evaluation and assessment to identify strengths and shortcomings with a focus on continuous improvement.
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http://dx.doi.org/10.1080/10903127.2021.1989530DOI Listing
March 2022

Simulation-Based Orientation for Emergency Medicine Residents Participating in EMS Ride-Alongs.

MedEdPORTAL 2021 9;17:11170. Epub 2021 Aug 9.

Associate Professor, Departments of Emergency Medicine and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai; System Director, Division of Emergency Medical Services, Mount Sinai Health System.

Introduction: Emergency medicine resident physicians are required to complete observational ride-alongs with emergency medical services (EMS) units as part of their curriculum as per the ACGME. We created this curriculum to expose emergency medicine residents to the equipment they will encounter in the prehospital setting, discuss basic EMS operations and the challenges of working in the prehospital environment, and review the limitations that restrict care provided by EMS professionals.

Methods: We created a series of five simulation cases for resident physicians participating in an EMS ride-along rotation. Each case was implemented with three to four residents at a time. A critical action checklist was used to assess participants during the scenarios. Following each simulation, a debriefing was conducted to discuss EMS operations and the impact on providers. At the conclusion of the session, participants completed a course evaluation survey.

Results: Thirteen emergency medicine resident physicians took part in this curriculum from October 2020 through January 2021. Results indicated that the participants gained insight into the prehospital environment, felt more prepared to complete their ride-alongs, and were engaged and satisfied with the introduction to EMS program.

Discussion: Simulation allowed emergency medicine residents to be exposed to the complex nature of prehospital care and prepared them for their ride-along sessions. The five cases provided significant breadth and depth of potential prehospital care issues, and the residents were able to discuss the medical, policy, and operational challenges presented as part of each case.
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http://dx.doi.org/10.15766/mep_2374-8265.11170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8349972PMC
August 2021

Correlation Between Paramedic Disaster Triage Accuracy in Screen-Based Simulations and Immersive Simulations.

Prehosp Emerg Care 2019 Jan-Feb;23(1):83-89. Epub 2018 Aug 21.

Disaster triage is an infrequent, high-stakes skill set used by emergency medical services (EMS) personnel. Screen-based simulation (SBS) provides easy access to asynchronous disaster triage education. However, it is unclear if the performance during a SBS correlates with immersive simulation performance. This was a nested cohort study within a randomized controlled trial (RCT). The RCT compared triage accuracy of paramedics and emergency medical technicians (EMTs) who completed an immersive simulation of a school shooting, interacted with an SBS for 13 weeks, and then completed the immersive simulation again. The participants were divided into two groups: those exposed vs. those not exposed to , a disaster triage SBS. The aim of the study was to measure the correlation between SBS triage accuracy and immersive simulation triage accuracy. Improvements in triage accuracy were compared among participants in the nested study before and after interacting with , and with improvements in triage accuracy in a previous study in which immersive simulations were used as an educational intervention. Thirty-nine participants completed the SBS; 26 (67%) completed at least three game plays and were included in the evaluation of outcomes of interest. The mean number of plays was 8.5 (SD =7.4). Subjects correctly triaged 12.4% more patients in the immersive simulation at study completion (73.1% before, 85.8% after, P = 0.004). There was no correlation between the amount of improvement in overall SBS triage accuracy, instances of overtriage (P = 0.101), instances of undertriage (P = 0.523), and improvement in the second immersive simulation. A comparison of the pooled data from a previous immersive simulation study with the nested cohort data showed similar improvement in triage accuracy (P = 0.079). SBS education was associated with a significant increase in triage accuracy in an immersive simulation, although triage accuracy demonstrated in the SBS did not correlate with the performance in the immersive simulation. This improvement in accuracy was similar to the improvement seen when immersive simulation was used as the educational intervention in a previous study.
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http://dx.doi.org/10.1080/10903127.2018.1475530DOI Listing
August 2020

60 Seconds to Survival: A Multisite Study of a Screen-based Simulation to Improve Prehospital Providers Disaster Triage Skills.

AEM Educ Train 2018 Apr 31;2(2):100-106. Epub 2018 Jan 31.

Department of Pediatrics Yale University School of Medicine New Haven CT.

Objectives: Paramedics and emergency medical technicians (EMTs) perform triage at disaster sites. There is a need for disaster triage training. Live simulation training is costly and difficult to deliver. Screen-based simulations may overcome these training barriers. We hypothesized that a screen-based simulation, 60 Seconds to Survival (60S), would be associated with in-game improvements in triage accuracy.

Methods: This was a prospective cohort study of a screen-based simulation intervention, 60S. Participants included emergency medical services (EMS) personnel from 21 EMS agencies across 12 states. Participants performed assessments (e.g., check for pulse) and actions (e.g., reposition the airway) for 12 patients in each scenario and assigned color-coded triage levels (red, yellow, green, or black) to each patient. Participants received on-screen feedback about triage performance immediately after each scenario. A scoring system was designed to encourage accurate and timely triage decisions. Participants who played 60S included practicing EMTs, paramedics, and nurses as well as students studying to assume these roles. Participants played the game at least three times over 13 weeks.

Results: In total, 2,234 participants began game play and 739 completed the study and were included in the analysis. Overall, the median number of plays of the game was just above the threshold inclusion criteria (three or more plays) with a median of four plays during the study period (interquartile range [IQR] = 3-7). There was a significant difference in triage accuracy from the first play of the game to the last play of the game. Median baseline triage accuracy in the game was 89.7% (IQR = 82.1%-94.9%), which then increased to a median of 100% at the last game play (IQR = 87.5%-100.0%; p < 0.001). There was some variability in median triage accuracy on fourth through 11th game plays, ranging from 95% to 100%, and on the 12th to 16th plays, the median accuracy was sustained at 100%. There was a significant decrease in the rate of undertriage: from 10.3% (IQR = 5.1%-18.0%) to 0 (IQR = 0%-12.5%; p < 0.001).

Conclusion: 60 Seconds to Survival is associated with improved in-game triage accuracy. Further study of the correlation between in-game triage accuracy and improvements in live simulation or real-world triage decisions is warranted.
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http://dx.doi.org/10.1002/aet2.10080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5996818PMC
April 2018

National Assessment of Quality Programs in Emergency Medical Services.

Prehosp Emerg Care 2018 May-Jun;22(3):370-378. Epub 2018 Jan 3.

Objective: This study aims to understand the adoption of clinical quality measurement throughout the United States on an EMS agency level, the features of agencies that do participate in quality measurement, and the level of physician involvement. It also aims to barriers to implementing quality improvement initiatives in EMS.

Methods: A 46-question survey was developed to gather agency level data on current quality improvement practices and measurement. The survey was distributed nationally via State EMS Offices to EMS agencies nation-wide using Surveymonkey©. A convenience sample of respondents was enrolled between August and November, 2015. Univariate, bivariate and multiple logistic regression analyses were conducted to describe demographics and relationships between outcomes of interest and their covariates using SAS 9.3©.

Results: A total of 1,733 surveys were initiated and 1,060 surveys had complete or near-complete responses. This includes agencies from 45 states representing over 6.23 million 9-1-1 responses annually. Totals of 70.5% (747) agencies reported dedicated QI personnel, 62.5% (663) follow clinical metrics and 33.3% (353) participate in outside quality or research program. Medical director hours varied, notably, 61.5% (649) of EMS agencies had <5 hours of medical director time per month. Presence of medical director time was correlated with tracking of QI measures. Air medical [OR 9.64 (1.13, 82.16)] and hospital-based EMS agencies [OR 2.49 (1.36, 4.59)] were more likely to track quality measures compared to fire-based agencies. Agencies in rural only environments were less likely to follow clinical quality metrics. (OR 0.47 CI 0.31 -0.72 p < 0.0004). For those that track QI measures, the most common are; Response Time (Emergency) (68.3%), On-Scene Time (66.4%), prehospital stroke screen (64.6%), aspirin administration (64.5%), and 12 lead ECG in chest pain patients (63.0%).

Conclusions: EMS agencies in the United States have significant practice variability with regard to quality improvement resources, medical direction and specific clinical quality measures. More research is needed to understand the impact of this variation on patient care outcomes.
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http://dx.doi.org/10.1080/10903127.2017.1380094DOI Listing
April 2019

60 seconds to survival: A pilot study of a disaster triage video game for prehospital providers.

Am J Disaster Med 2017 ;12(2):75-83

Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut.

Introduction: Disaster triage training for emergency medical service (EMS) providers is not standardized. Simulation training is costly and time-consuming. In contrast, educational video games enable low-cost and more time-efficient standardized training. We hypothesized that players of the video game "60 Seconds to Survival" (60S) would have greater improvements in disaster triage accuracy compared to control subjects who did not play 60S.

Methods: Participants recorded their demographics and highest EMS training level and were randomized to play 60S (intervention) or serve as controls. At baseline, all participants completed a live school-shooting simulation in which manikins and standardized patients depicted 10 adult and pediatric victims. The intervention group then played 60S at least three times over the course of 13 weeks (time 2). Players triaged 12 patients in three scenarios (school shooting, house fire, tornado), and received in-game performance feedback. At time 2, the same live simulation was conducted for all participants. Controls had no disaster training during the study. The main outcome was improvement in triage accuracy in live simulations from baseline to time 2. Physicians and EMS providers predetermined expected triage level (RED/YELLOW/GREEN/BLACK) via modified Delphi method.

Results: There were 26 participants in the intervention group and 21 in the control group. There was no difference in gender, level of training, or years of EMS experience (median 5.5 years intervention, 3.5 years control, p = 0.49) between the groups. At baseline, both groups demonstrated median triage accuracy of 80 percent (IQR 70-90 percent, p = 0.457). At time 2, the intervention group had a significant improvement from baseline (median accuracy = 90 percent [IQR: 80-90 percent], p = 0.005), while the control group did not (median accuracy = 80 percent [IQR:80-95], p = 0.174). However, the mean improvement from baseline was not significant between the two groups (difference = 6.5, p = 0.335).

Conclusion: The intervention demonstrated a significant improvement in accuracy from baseline to time 2 while the control did not. However, there was no significant difference in the improvement between the intervention and control groups. These results may be due to small sample size. Future directions include assessment of the game's effect on triage accuracy with a larger, multisite site cohort and iterative development to improve 60S.
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http://dx.doi.org/10.5055/ajdm.2017.0263DOI Listing
April 2018

A mobile medical care approach targeting underserved populations in post-Hurricane Katrina Mississippi.

J Health Care Poor Underserved 2007 May;18(2):331-40

Department of Pediatrics, University of Toledo College of Medicine, 3120 Glendale Avenue, Toledo, OH 43614, USA.

On August 29, 2005, Hurricane Katrina devastated the Gulf Coast Mississippi region, damaging health care infrastructure and adversely affecting the health of populations left behind. Operation Assist, a project of the Children's Health Fund and the Columbia University Mailman School of Public Health, operated mobile medical units to provide health services to underserved populations in the affected areas. Data collected from all patient encounters from September 5-20, 2005 demonstrate that in addition to common respiratory illnesses, skin conditions, and minor injuries, a high proportion of visits were for vaccine administration and chronic medical problems including hypertension, diabetes, and asthma. Mobile medical units staffed by primary care clinicians experienced in dealing with the clinical and social needs of the underserved and comfortable working in a resource-poor environment can make a positive contribution to post-disaster care.
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http://dx.doi.org/10.1353/hpu.2007.0038DOI Listing
May 2007
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