In Situ Simulation for Adoption of New Technology to Improve Sepsis Care in Rural Emergency Departments.

Objectives: The aims of the study were to evaluate whether in situ (on-site) simulation training is associated with increased telemedicine use for patients presenting to rural emergency departments (EDs) with severe sepsis and septic shock and to evaluate the association between simulation training and telehealth with acute sepsis bundle (SEP-1) compliance and mortality.

Methods: This was a quasi-experimental study of patients presenting to 2 rural EDs with severe sepsis and/or septic shock before and after rollout of in situ simulation training that included education on sepsis management and the use of telehealth. Unadjusted and adjusted analyses were conducted to describe the association of simulation training with sepsis process of care markers and with mortality.

A novel in situ simulation framework for introduction of a new technology: the 3-Act-3-Debrief model.

Background: New technologies for clinical staff are typically introduced via an "in-service" that focuses on knowledge and technical skill. Successful adoption of new healthcare technologies is influenced by multiple other factors as described by the Consolidated Framework in Implementation Research (CFIR). A simulation-based introduction to new technologies provides opportunity to intentionally address specific factors that influence adoption.

Sepsis Alerts in Emergency Departments: A Systematic Review of Accuracy and Quality Measure Impact.

Introduction: For early detection of sepsis, automated systems within the electronic health record have evolved to alert emergency department (ED) personnel to the possibility of sepsis, and in some cases link them to suggested care pathways. We conducted a systematic review of automated sepsis-alert detection systems in the ED.

Methods: We searched multiple health literature databases from the earliest available dates to August 2018.

A Simple Low-Cost Method to Integrate Telehealth Interprofessional Team Members During In Situ Simulation.

Introduction: With the growth of telehealth, simulation personnel will be called upon to support training that integrates these new technologies and processes. We sought to integrate remote telehealth electronic intensive care unit (eICU) personnel into in situ simulations with rural emergency department (ED) care teams. We describe how we overcame technical challenges of creating shared awareness of the patient's condition and the care team's progress among those executing the simulation, the care team, and the eICU.

Emergency Department-Based Palliative Interventions: A Novel Approach to Palliative Care in the Emergency Department.

Patients with cancer and palliative care needs frequently use the emergency department (ED). ED-based palliative services may extend the reach of palliative care for these patients. To assess the feasibility and reach of an ED-based palliative intervention (EPI) program.

Inpatient Trauma Mortality after Implementation of the Affordable Care Act in Illinois.

Introduction: Illinois hospitals have experienced a marked decrease in the number of uninsured patients after implementation of the Affordable Care Act (ACA). However, the full impact of health insurance expansion on trauma mortality is still unknown. The objective of this study was to determine the impact of ACA insurance expansion on trauma patients hospitalized in Illinois.

Emergency Department Use across 88 Small Areas after Affordable Care Act Implementation in Illinois.

Introduction: This study analyzes changes in hospital emergency department (ED) visit rates before and after the 2014 Affordable Care Act (ACA) insurance expansions in Illinois. We compare the association between population insurance status change and ED visit rate change between a 24-month (2012-2013) pre-ACA period and a 24-month post-ACA (2014-2015) period across 88 socioeconomically diverse areas of Illinois.

Methods: We used annual American Community Survey estimates for 2012-2015 to obtain insurance status changes for uninsured, private, Medicaid, and Medicare (disability) populations of 88 Illinois Public Use Micro Areas (PUMAs), areas with a mean of about 90,000 age 18-64 residents.

Characterizing Teamwork in Cardiovascular Care Outcomes: A Network Analytics Approach.

Background: The nature of teamwork in healthcare is complex and interdisciplinary, and provider collaboration based on shared patient encounters is crucial to its success. Characterizing the intensity of working relationships with risk-adjusted patient outcomes supplies insight into provider interactions in a hospital environment.

Methods And Results: We extracted 4 years of patient, provider, and activity data for encounters in an inpatient cardiology unit from Northwestern Medicine's Enterprise Data Warehouse.

Emergency Department Visits and Hospitalizations for the Uninsured in Illinois Before and After Affordable Care Act Insurance Expansion.

We describe changes in emergency department (ED) visits and the proportion of patients with hospitalizations through the ED classified as Ambulatory Care Sensitive Hospitalization (ACSH) for the uninsured before (2011-2013) and after (2014-2015) Affordable Care Act (ACA) health insurance expansion in Illinois. Hospital administrative data from 201 non-federal Illinois hospitals for patients age 18-64 were used to analyze ED visits and hospitalizations through the ED. ACSH was defined using Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators (PQIs).

Increased Emergency Department Use in Illinois After Implementation of the Patient Protection and Affordable Care Act.

Study Objective: We examine emergency department (ED) use and hospitalizations through the ED after Patient Protection and Affordable Care Act (ACA) health insurance expansion in Illinois, a Medicaid expansion state.

Methods: Using statewide hospital administrative data from 2011 through 2015 from 201 nonfederal Illinois hospitals for patients aged 18 to 64 years, mean monthly ED visits were compared before and after ACA implementation by disposition from the ED and primary payer. Visit data were combined with 2010 to 2014 census insurance estimates to compute payer-specific ED visit rates.

Relationship between racial disparities in ED wait times and illness severity.

Background: Prolonged emergency department (ED) wait times could potentially lead to increased mortality. Studies have demonstrated that black patients waited significantly longer for ED care than nonblack patients. However, the disparity in wait times need not necessarily manifest across all illness severities.

National trends in the use of postcardiac arrest therapeutic hypothermia and hospital factors influencing its use.

Background: Therapeutic hypothermia (TH) in cardiac arrest continues to be underused in the United States. A better understanding of its utilization could inform future efforts and policies to improve utilization. This study investigates trends in TH use for in and out-of-hospital cardiac arrest, and hospital factors associated with its use.

Failure mode effects and criticality analysis: innovative risk assessment to identify critical areas for improvement in emergency department sepsis resuscitation.

Background: Sepsis is an increasing problem in the practice of emergency medicine as the prevalence is increasing and optimal care to reduce mortality requires significant resources and time. Evidence-based septic shock resuscitation strategies exist, and rely on appropriate recognition and diagnosis, but variation in adherence to the recommendations and therefore outcomes remains. Our objective was to perform a multi-institutional prospective risk-assessment, using failure mode effects and criticality analysis (FMECA), to identify high-risk failures in ED sepsis resuscitation.

The weekend effect for patients with sepsis presenting to the emergency department.

Background: Mortality differences in weekend and weekday admissions have been observed for a variety of conditions that require aggressive early intervention. It is unknown if there is a mortality difference that exists for patients presenting to the Emergency Department (ED) with sepsis on the weekend.

Study Objectives: We hypothesized that there is an increase in early inpatient mortality (death on day 1 or day 2 of hospitalization) among patients with sepsis who present to the ED on the weekend vs.

Use of risk assessment analysis by failure mode, effects, and criticality to reduce door-to-balloon time.

Study Objective: The Centers for Medicare & Medicaid Services currently endorses a door-to-balloon time of 90 minutes or less for patients presenting to the emergency department (ED) with ST-segment elevation myocardial infarction. Recent evidence shows that a door-to-balloon time of 60 minutes significantly decreases inhospital mortality. We seek to use a proactive risk assessment method of failure mode, effects, and criticality analysis (FMECA) to evaluate door-to-balloon time process, to investigate how each component failure may affect the performance of a system, and to evaluate the frequency and the potential severity of harm of each failure.

Time to antibiotics for septic shock: evaluating a proposed performance measure.

Purposes: International guidelines recommend antibiotics within 1 hour of septic shock recognition; however, a recently proposed performance measure is focused on measuring antibiotic administration within 3 hours of emergency department (ED) arrival. Our objective was to describe the time course of septic shock and subsequent implications for performance measurement.

Basic Procedures: Cross-sectional study of consecutive ED patients ultimately diagnosed with septic shock.

Cost-effectiveness of a novel indication of computed tomography of the coronary arteries.

Objective: A common strategy for excluding coronary artery disease among patients presenting with low-risk chest pain is observation unit (OU) admission with serial cardiac biomarkers and stress testing for cardiac risk stratification. Patients with positive- or indeterminate-stress tests are often admitted for cardiac catheterization despite a low likelihood of disease. The aim of this study is to estimate the cost-effectiveness of computed tomography of the coronary arteries (CTCA) in the OU for the evaluation of low-risk chest pain patients with indeterminate- or positive-stress test results.

Hospital-reported data on the pneumonia quality measure "Time to First Antibiotic Dose" are not associated with inpatient mortality: results of a nationwide cross-sectional analysis.

Objectives: Significant controversy exists regarding the Centers for Medicare & Medicaid Services (CMS) "time to first antibiotics dose" (TFAD) quality measure. The objective of this study was to determine whether hospital performance on the TFAD measure for patients admitted from the emergency department (ED) for pneumonia is associated with decreased mortality.

Methods: This was a cross-sectional analysis of 95,704 adult ED admissions with a principal diagnosis of pneumonia from 530 hospitals in the 2007 Nationwide Inpatient Sample.

Lower mortality in sepsis patients admitted through the ED vs direct admission.

Purpose: Early aggressive resuscitation in patients with severe sepsis decreases mortality but requires extensive time and resources. This study analyzes if patients with sepsis admitted through the emergency department (ED) have lower inpatient mortality than do patients admitted directly to the hospital.

Procedures: We performed a cross-sectional analysis of hospitalizations with a principal diagnosis of sepsis in institutions with an annual minimum of 25 ED and 25 direct admissions for sepsis, using data from the 2008 Nationwide Inpatient Sample.

The relationship between inpatient discharge timing and emergency department boarding.

Background: Patient crowding and boarding in Emergency Departments (EDs) impair the quality of care as well as patient safety and satisfaction. Improved timing of inpatient discharges could positively affect ED boarding, and this hypothesis can be tested with computer modeling.

Study Objective: Modeling enables analysis of the impact of inpatient discharge timing on ED boarding.

Volume of emergency department admissions for sepsis is related to inpatient mortality: results of a nationwide cross-sectional analysis.

Objectives: Emergency department resuscitation plays a significant role in sepsis care, and it is unknown if patient outcomes vary by institution based on the level of sepsis experience of the emergency department. This study examines whether there is an association between the annual volume of patients admitted via the emergency department with sepsis and inpatient mortality.

Design: Cross-sectional analysis of the 2007 Nationwide Inpatient Sample.

Pancreatic fistula following pancreaticoduodenectomy: clinical predictors and patient outcomes.

Pancreatic fistula continues to be a common complication following PD. This study seeks to identify clinical factors which may predict pancreatic fistula (PF) and evaluate the effect of PF on outcomes following pancreaticoduodenectomy (PD). We performed a retrospective analysis of a clinical database at an academic tertiary care hospital with a high volume of pancreatic surgery.

Sixty-four-slice computed tomography of the coronary arteries: cost-effectiveness analysis of patients presenting to the emergency department with low-risk chest pain.

Objectives: The aim was to use a computer model to estimate the cost-effectiveness of 64-slice multidetector computed tomography (MDCT) of the coronary arteries in the emergency department (ED) compared to an observation unit (OU) stay plus stress electrocardiogram (ECG) or stress echocardiography for the evaluation of low-risk chest pain patients presenting to the ED.

Methods: A decision analytic model was developed to compare health outcomes and costs that result from three different risk stratification strategies for low-risk chest pain patients in the ED: stress ECG testing after OU care, stress echocardiography after OU care, and MDCT with no OU care. Three patient populations were modeled with the prevalence of symptomatic coronary artery disease (CAD) being very low risk, 2%; low risk, 6% (base case); and moderate risk, 10%.

Diagnostic uncertainty and costs associated with current emergency department evaluation of low risk chest pain.

Introduction: Of all stress tests done in low risk Emergency Department observation units (OU), a small, but significant number may be reported as positive or indeterminate. The objective of this study is to quantify the prevalence and costs associated with positive and indeterminate stress tests that result in negative cardiac catheterization.

Methods: Retrospective observational cohort study over 9 months.