Benjamin A. White

Health impact assessment and short-term medical missions: A methods study to evaluate quality of care

BackgroundShort-term medical missions (STMMs) are a well-established means of providing health care to the developing world. Despite over 250 million dollars and thousands of volunteer hours dedicated to STMMs, there is a lack of standardized evaluation to assess patient safety, quality control, and mission impact. The objective of this project is to design and implement an assessment tool that defines objective parameters of quality of care as identified by STMMs.MethodsThe study was conducted in 3 phases: 1) Base-need analysis to determine factors critical to the quality of STMMs, 2) Design of 5 surveys for mission personnel and patients to enable 360-degree evaluation based on factors from phase 1, and 3) Field testing of the surveys with 5 STMMs.ResultsAn evaluation tool was created assessing 6 major and 30 minor factors identified as important to the quality of STMMs. 5 mission directors, 43 personnel, 10 local hosts, and 55 patients completed the surveys. Of the 6 major measures of quality, missions performed best in Cost (mean score 86%), and Impact (84%). The poorest performance was in Education (64%). Efficiency, Sustainability, and Preparedness showed mean scores of 76%, 77%, and 73%, respectively.ConclusionOur study provides a novel standardized tool for STMM evaluation. Use of the assessment instrument identified areas of strength and weakness of a particular mission, and delineated general trends in performance compared to other STMMs. We anticipate that the use of this tool may improve the quality of care provided by missions, and stimulate solution-sharing and scholarly discussion among missions.

Boarding Inpatients in the Emergency Department Increases Discharged Patient Length of Stay

BACKGROUND Boarding of inpatients in the Emergency Department (ED) has been widely recognized as a major contributor to ED crowding and a cause of adverse outcomes. We hypothesize that these deleterious effects extend to those patients who are discharged from the ED by increasing their length of stay (LOS). STUDY OBJECTIVES This study investigates the impact of boarding inpatients on the ED LOS of discharged patients. METHODS This retrospective, observational, cohort study investigated the association between ED boarder burden and discharged patient LOS over a 3-year period in an urban, academic tertiary care ED. Median ED LOS of 179,840 discharged patients was calculated for each quartile of the boarder burden at time of arrival, and Spearman correlation coefficients were used to summarize the relationship. Subgroup analyses were conducted, stratified by patient acuity defined by triage designation, and hour of arrival. RESULTS Overall median discharged patient ED LOS increased by boarder burden quartile (205 [95% confidence interval (CI) 203-207], 215 [95% CI 214-217], 221 [95% CI 219-223], and 221 [95% CI 219-223] min, respectively), with a Spearman correlation of 0.25 between daily total boarder burden hours and median LOS. When stratified by patient acuity and hour of arrival (11:00 a.m.-11:00 p.m.), LOS of medium-acuity patients increased significantly by boarder burden quartile (252 [95% CI 247-255], 271 [95% CI 267-275], 285 [95% CI 95% CI 278-289], and 309 [95% CI 305-315] min, respectively) with a Spearman correlation of 0.18. CONCLUSION In this retrospective study, increasing boarder burden was associated with increasing LOS of patients discharged from the ED, with the greatest effect between 11:00 a.m. and 11:00 p.m. on medium-acuity patients. This relationship between LOS and ED capacity limitation by inpatient boarders has important implications, as ED and hospital leadership increasingly focus on ED LOS as a measure of efficiency and throughput.

Perceived Need for Dental Care Among Persons Living with Acquired Immunodeficiency Syndrome

Compromised oral health holds significant implications for the general health of medically vulnerable, HIV infected individuals. Past studies have reported that these individuals frequently suffer from oral opportunistic infections and have a tendency to develop severe periodontal disease. This study extends past research by examining the prevalence of oral infections according to patient characteristics and by reporting, for the first time, the level of perceived dental need in a large, multi-site sample of individuals with symptomatic HIV disease. Data for this study come from a survey of 857 clients of the Robert Wood Johnson Foundations AIDS Health Services Program in 9 U.S. cities. More respondents (52%) reported a need for dental care than for any other service need. Multivariate analysis showed that clients who were white, in low-income groups, used intravenous drugs, or had a past history of oral opportunistic infections were more likely to report dental need. Relations between age, gender, insurance status, or disease status and perceived need were statistically nonsignificant. Forty-seven percent of the clients reported they had an oral opportunistic infection, the second outcome variable examined in this study. Statistically significant differences (P < 0.05) were found in the prevalence of oral opportunistic infections among race and disease severity groups. Whites and the more severely ill were more likely to report an infection than their respective counterparts.

Supplemented Triage and Rapid Treatment (START) Improves Performance Measures in the Emergency Department

BACKGROUND Emergency Department (ED) crowding is well recognized, and multiple studies have demonstrated its negative effect on patient care. STUDY OBJECTIVES This study aimed to assess the effect of an intervention, Supplemented Triage and Rapid Treatment (START), on standard ED performance measures. The START program complemented standard ED triage with a team of clinicians who initiated the diagnostic work-up and selectively accelerated disposition in a subset of patients. METHODS This retrospective before-after study compared performance measures over two 3-month periods (September-November 2007 and 2008) in an urban, academic tertiary care ED. Data from an electronic patient tracking system were queried over 12,936 patients pre-intervention, and 14,220 patients post-intervention. Primary outcomes included: 1) overall length of stay (LOS), 2) LOS for discharged and admitted patients, and 3) the percentage of patients who left without complete assessment (LWCA). RESULTS In the post-intervention period, patient volume increased 9% and boarder hours decreased by 1.3%. Median overall ED LOS decreased by 29 min (8%, 361 min pre-intervention, 332 min post-intervention; p < 0.001). Median LOS for discharged patients decreased by 23 min (7%, 318 min pre-intervention, 295 min post-intervention; p < 0.001), and by 31 min (7%, 431 min pre-intervention, 400 min post-intervention) for admitted patients. LWCA was decreased by 1.7% (4.1% pre-intervention, 2.4% post-intervention; p < 0.001). CONCLUSIONS In this study, a comprehensive screening and clinical care program was associated with a significant decrease in overall ED LOS, LOS for discharged and admitted patients, and rate of LWCA, despite an increase in ED patient volume.

A long-term analysis of physician triage screening in the emergency department.

OBJECTIVES The problem of emergency department (ED) crowding is well recognized; however, little data exist on the sustainability of potential solutions, including physician triage and screening. The authors hypothesized that a physician triage screening program (Supplemented Triage and Rapid Treatment [START]) sustainably improves standard ED performance metrics. METHODS This retrospective, observational, before-and-after study compared performance measures over 4 years in a tertiary care urban academic medical center with approximately 90,000 annual ED visits. Patients seen between December 2006 and November 2010 were included. Outcome measures included length of stay (LOS) for ED patients, percentage of patients who left without completing assessment (LWCA), percentage of patients treated and dispositioned by START without using monitored beds, and door-to-room time. Descriptive statistics were used. RESULTS Median LOS for START patients was 56 minutes/patient lower when comparing 2010 to 2007 (p < 0.0001) and for non-START patients 22 minutes/patient lower (p < 0.0001). The percentage of patients who LWCA decreased from 4.8% to 2.9% (p < 0.0001) during the same time period. In STARTs first half-year, 18% of patients were discharged without using monitored beds. This increased to 29% by year 3. In addition, median door-to-room time decreased from 18.4 to 9.9 minutes during the same 3-year interval. CONCLUSIONS Physician screening appears to provide sustainable improvements in ED performance metrics including ED LOS, percentage of patients who LWCA, door-to-room time, and percentage of patients treated without using a monitored bed, despite increasing ED volume. Physician screening delivers additional incremental benefits for several years after implementation and can effectively increase ED capacity by allowing emergency physicians to more efficiently use monitored beds.

Impact of Physician Screening in the Emergency Department on Patient Flow

BACKGROUND Physician triage is one of many front-end interventions being implemented to improve emergency department (ED) efficiency. STUDY OBJECTIVE We aim to determine the impact of this intervention on some key components of ED patient flow, including time to physician evaluation, treatment order entry, diagnostic order entry, and disposition time for admitted patients. METHODS We conducted a 2-year before-after analysis of a physician triage system at an urban tertiary academic center with 90,000 annual visits. The goal of the physician in triage was to arrange safe disposition of straightforward patients as well as to initiate work-ups. All medium-acuity patients arriving during the hours of the intervention were impacted and thus included in the analysis. Our primary outcome was the time to disposition decision. In addition to before-after analysis, comparison was made with high-acuity patients, a group not impacted by this intervention. Patient flow data were extracted from the ED information system. Outcomes were summarized with medians and interquartiles. Multivariable regression analysis was performed to investigate the intervention effect controlling for potential confounding variables. RESULTS The median time to disposition decision decreased by 6min, and the time to physician evaluation, analgesia, antiemetic, antibiotic, and radiology order decreased by 16, 70, 66, 36, and 16min, respectively. These findings were all statistically significant. Similar results were observed from the multivariable regression models after controlling for potential confounding factors. CONCLUSIONS Physician triage led to earlier evaluation, physician orders, and a decrease in the time to disposition decision.

Using Lean-Based Systems Engineering to Increase Capacity in the Emergency Department

Introduction While emergency department (ED) crowding has myriad causes and negative downstream effects, applying systems engineering science and targeting throughput remains a potential solution to increase functional capacity. However, the most effective techniques for broad application in the ED remain unclear. We examined the hypothesis that Lean-based reorganization of Fast Track process flow would improve length of stay (LOS), percent of patients discharged within one hour, and room use, without added expense. Methods This study was a prospective, controlled, before-and-after analysis of Fast Track process improvements in a Level 1 tertiary care academic medical center with >95,000 annual patient visits. We included all adult patients seen during the study periods of 6/2010–10/2010 and 6/2011–10/2011, and data were collected from an electronic tracking system. We used concurrent patients seen in another care area used as a control group. The intervention consisted of a simple reorganization of patient flow through existing rooms, based in systems engineering science and modeling, including queuing theory, demand-capacity matching, and Lean methodologies. No modifications to staffing or physical space were made. Primary outcomes included LOS of discharged patients, percent of patients discharged within one hour, and time in exam room. We compared LOS and exam room time using Wilcoxon rank sum tests, and chi-square tests for percent of patients discharged within one hour. Results Following the intervention, median LOS among discharged patients was reduced by 15 minutes (158 to 143 min, 95%CI 12 to 19 min, p<0.0001). The number of patients discharged in <1 hr increased by 2.8% (from 6.9% to 9.7%, 95%CI 2.1% to 3.5%, p<0.0001), and median exam room time decreased by 34 minutes (90 to 56 min, 95%CI 31 to 38 min, p<0.0001). In comparison, the control group had no change in LOS (265 to 267 min) or proportion of patients discharged in <1 hr (2.9% to 2.9%), and an increase in exam room time (28 to 36 min, p<0.0001). Conclusion In this single center trial, a focused Lean-based reorganization of patient flow improved Fast Track ED performance measures and capacity, without added expense. Broad multi-centered application of systems engineering science might further improve ED throughput and capacity.

Operational and financial impact of physician screening in the ED

BACKGROUND Physician screening is one of many front-end interventions being implemented to improve emergency department (ED) efficiency. STUDY OBJECTIVE We aimed to quantify the operational and financial impact of this intervention at an urban tertiary academic center. METHODS We conducted a 2-year before-after analysis of a physician screening system at an urban tertiary academic center with 90 000 annual visits. Financial impact consisted of the ED and inpatient revenue generated from the incremental capacity and the reduction in left without being seen (LWBS) rates. The ED and inpatient margin contribution as well as capital expenditure were based on available published data. We summarized the financial impact using net present value of future cash flows performing sensitivity analysis on the assumptions. Operational outcome measures were ED length of stay and percentage of LWBS. RESULTS During the first year, we estimate the contribution margin of the screening system to be

A structured PBL tutorial involving small teams for teaching the human nervous system.

2.71 million and the incremental operational cost to be

Applying Systems Engineering Reduces Radiology Transport Cycle Times in the Emergency Department

1.86 million. Estimated capital expenditure for the system was