Kristy Kummerow Broman

Postoperative Care Using a Secure Online Patient Portal: Changing the (Inter)Face of General Surgery

BACKGROUND Many patients seek greater accessibility to health care. Meanwhile, surgeons face increasing time constraints due to workforce shortages and elevated performance demands. Online postoperative care may improve patient access while increasing surgeon efficiency. We aimed to evaluate patient and surgeon acceptance of online postoperative care after elective general surgical operations. STUDY DESIGN A prospective pilot study within an academic general surgery service compared online and in-person postoperative visits from May to December 2014. Included patients underwent elective laparoscopic cholecystectomy, laparoscopic ventral hernia repair, umbilical hernia repair, or inguinal hernia repair by 1 of 5 surgeons. Patients submitted symptom surveys and wound pictures, then corresponded with their surgeons using an online patient portal. The primary outcome was patient-reported acceptance of online visits in lieu of in-person visits. Secondary outcomes included detection of complications via online visits, surgeon-reported effectiveness, and visit times. RESULTS Fifty patients completed both online and in-person visits. Online visits were acceptable to most patients as their only follow-up (76%). For 68% of patients, surgeons reported that both visit types were equally effective, while clinic visits were more effective in 24% and online visits in 8%. No complications were missed via online visits, which took significantly less time for patients (15 vs 103 minutes, p < 0.01) and surgeons (5 vs 10 minutes, p < 0.01). CONCLUSIONS In this population, online postoperative visits were accepted by patients and surgeons, took less time, and effectively identified patients who required further care. Further evaluation is needed to establish the safety and potential benefit of online postoperative visits in specific populations.

Closing the loop: a process evaluation of inpatient care team communication

Interprofessional communication is a core component of healthcare delivery in inpatient settings and a key contributor to safe and efficient inpatient care. Communication is implicated in two-thirds of medical errors and accounts for a significant proportion of nurse and clinician time.1–4 Inpatient teams rely on multiple communication methods ranging from paging and stationary telephones to wireless mobile devices, but comparative evaluations of communication systems are largely limited to qualitative outcomes.5–10 With respect to safety and efficiency, key measures of communication system performance include frequency of task disruption and reliability of ‘closed loop’ communication, meaning the sender receives a sufficient response to address the communication need. We sought to understand communication processes in two different patient care areas of a single hospital using traditional (non-mobile) versus mobile phones and to quantify how each mode of communication affects task disruption, efficiency and reliability of closed-loop communication. Our interprofessional team of providers, nurses and administrative leaders mapped processes for nurse-to-provider communication on two types of medical and surgical units that use different communication systems at Vanderbilt University Medical Center, a southeastern US academic medical centre. In both settings, nurses initiated messages by sending alphanumeric pages to clinicians. In the traditional (non-mobile) setting, providers called back a stationary unit phone, typically answered by the unit medical receptionist, who then located the nurse to answer the phone. In the …

Insurance status influences emergent designation in surgical transfers

BACKGROUND There is a perception among surgeons that hospitals disproportionately transfer unfavorably insured patients for emergency surgical care. Emergency medical condition (EMC) designation mandates referral center acceptance of patients for whom transfer is requested. We sought to understand whether unfavorably insured patients are more likely to be designated as EMCs. MATERIALS AND METHODS A retrospective cohort study was performed on patient transfers from a large network of acute care facilities to emergency surgery services at a tertiary referral center from 2009-2013. Insurance was categorized as favorable (commercial or Medicare) or unfavorable (Medicaid or uninsured). The primary outcome, transfer designation as EMC or non-EMC, was evaluated using multivariable logistic regression. A secondary analysis evaluated uninsured patients only. RESULTS There were 1295 patient transfers in the study period. Twenty percent had unfavorable insurance. Favorably insured patients were older with fewer nonwhite, more comorbidities, greater illness severity, and more likely transferred for care continuity. More unfavorably insured patients were designated as EMCs (90% versus 84%, P < 0.01). In adjusted models, there was no association between unfavorable insurance and EMC transfer (odds ratio [OR], 1.61; 95% confidence interval [CI], 0.98-2.69). Uninsured patients were more likely to be designated as EMCs (OR, 2.27; CI, 1.08-4.77). CONCLUSIONS The finding that uninsured patients were more likely to be designated as EMCs suggests nonclinical variation that may be mitigated by clearer definitions and increased interfacility coordination to identify patients requiring transfer for EMCs.