Use of Emergency Department Extracorporeal Membrane Oxygenation for Treatment of Acute Necrotizing Myocarditis.

We report a case of acute necrotizing eosinophilic myocarditis (ANEM) secondary to drug rash with eosinophilia and systemic symptoms (DRESS) related to administration of minocycline. Myocarditis is a rare complication of DRESS and can manifest as either a self-limited hypersensitivity myocarditis or as the frequently fatal ANEM. Due to the high morbidity and mortality caused by this disease, emergency physicians should be aware of the potential of ANEM in patients with history of DRESS and new-onset cardiac dysfunction. This case reviews the clinical presentation and management of ANEM and the potential role of extracorporeal membrane oxygenation use in the emergency department.

Telemedicine Delivery and Successful Reimbursement in Toxicology.

INTRODUCTION: Telemedicine and its use in medical toxicology have existed for some time. There are varied definitions, but existing ones center on using currently available forms of audio, video, and internet communications to provide "real-time" patient care. Definitions have historically limited reimbursement but recently expanded CMS guidelines have improved this. Here we describe our experience with telemedicine and reimbursement. METHODS: A retrospective study was conducted of all toxicology and billing reimbursement for fiscal year 2016 for a solo Medical Toxicology service. Clinical identifiers were used to match telemedicine consults to hospital financial databases and then removed. Telemedicine consults were isolated, quantified, and described. RESULTS: A total of 16 telemedicine consults were conducted. Average age was 37.2 (range 2 months-82 years). Gender was evenly split at 8:8. Twenty-five percent were pediatric consultations. The main purposes of consultation were as follows: diagnosis and disease management in drug ingestion, triage assistance, clearance consults, antidote administration, and buprenorphine induction. At the time of the work, $1896.00 for 9.3 h of teletoxicology services was reimbursed equating to an hourly reimbursement rate of $203.90/h. LIMITATIONS: Our data was obtained from a toxicology practice with a surrounding infrastructure dedicated to telemedicine. All sites may not have this robust ancillary support. Furthermore, not all states have reimbursement mandates such as New York State. CONCLUSION: To our knowledge, this is the first published work describing pilot data in the successful reimbursement for Medical Toxicology services delivered via telemedicine. Toxicology via telemedicine represents a great opportunity for advancing the practice of toxicology in an economically feasible way, particularly in rural or underserved areas.

Billing and reimbursement for a bedside toxicology service at a tertiary care academic center during its first fiscal year.

A bedside toxicology consult service may improve clinical care, facilitate patient clearance and disposition, and result in potential cost savings for poisoning exposures. Despite this, there is scant data regarding economic feasibility for such a service. Previously published information suggests low hourly reimbursement at approximately $26.00/h at the bedside for toxicology consultations. A bedside toxicology consultant service was initiated in 2011. Coverage was available 24 h a day for 50 out of 52 weeks. Bedside rounding on toxicology consult patients was available 6/7 days per week. The practice is associated with >800 bed teaching institution in a large upstate NY region with elements of urban and suburban practice. Demographic and billing data was collected for all patients consulted upon from July 1, 2011 to June 31, 2012. In charges of $514,941 were generated during the period of data collection. Monthly average was $42,912. Net reimbursement of charges was 29 % of overall charges at $147,792. In terms of total encounters, net collection rate in which something was reimbursed or "paid" against charges for that encounter was 82.6 % of all encounters at 999/1,210. Average encounter time for inpatients, including critical care, was 1.05 h, and the average time spent for outpatients was 1.18 h. Reimbursement rates appear higher than previously reported. Revenue generated from reimbursement from toxicology consultation can result in recouping a substantial portion of a toxicologist's salary or potentially fund fellowship positions and salaries or toxicology division infrastructure.

Entropy: a conceptual approach to measuring situation-level workload within emergency care and its relationship to emergency department crowding.

BACKGROUND: Emergency department (ED) crowding correlates with patient safety. Difficulties quantifying crowding and providing solutions were highlighted in the recent Institute of Medicine (IOM) report calling for the application of advanced industrial engineering (IE) research techniques to evaluate ED crowding. ED personnel workload is a related concept, with potential reciprocal effects between the two. Collaboration between emergency medicine and IE is needed to address crowding and ED personnel workload. OBJECTIVE: We review ED crowding and workload literature, relationships between workload and ED crowding, and the potential application of information theory as implemented in IE frameworks entitled "entropy" in evaluating both topics. DISCUSSION: IE techniques have applications for emergency medicine and have been successful in helping improve ED operations. Lean and Six Sigma applications are some of these techniques. Existing ED workload measures don't account for all aspects of work in the ED (acuity, efficiency, tasks, etc.) Crowding scales, such as NEDOCS (National ED Overcrowding Study) and EDWIN (ED Work Index), fail to predict ED crowding. A new measurement "entropy" may provide a more comprehensive evaluation of ED workload and may predict work overload seen with crowding. Entropy measures task-based work and the information flow involved. By assigning an entropy value to patient type-specific tasks, we might predict when the ED is overwhelmed, and crowded. CONCLUSIONS: IE techniques provide solutions to the ED crowding problem and improve ED workload. We propose a technique novel to medicine: "Entropy," derived from information theory, which may provide insight into ED personnel workload, its potential for measuring ED crowding, and possibly, in predicting an overwhelming situation.

The impact of interoperability of electronic health records on ambulatory physician practices: a discrete-event simulation study.

BACKGROUND: The effect of health information technology (HIT) on efficiency and workload among clinical and nonclinical staff has been debated, with conflicting evidence about whether electronic health records (EHRs) increase or decrease effort. None of this paper to date, however, examines the effect of interoperability quantitatively using discrete event simulation techniques. OBJECTIVE: To estimate the impact of EHR systems with various levels of interoperability on day-to-day tasks and operations of ambulatory physician offices. METHODS: Interviews and observations were used to collect workflow data from 12 adult primary and specialty practices. A discrete event simulation model was constructed to represent patient flows and clinical and administrative tasks of physicians and staff members. RESULTS: High levels of EHR interoperability were associated with reduced time spent by providers on four tasks: preparing lab reports, requesting lab orders, prescribing medications, and writing referrals. The implementation of an EHR was associated with less time spent by administrators but more time spent by physicians, compared with time spent at paper-based practices. In addition, the presence of EHRs and of interoperability did not significantly affect the time usage of registered nurses or the total visit time and waiting time of patients. CONCLUSION: This paper suggests that the impact of using HIT on clinical and nonclinical staff work efficiency varies, however, overall it appears to improve time efficiency more for administrators than for physicians and nurses.

Measures of crowding in the emergency department: a systematic review.

OBJECTIVES: Despite consensus regarding the conceptual foundation of crowding, and increasing research on factors and outcomes associated with crowding, there is no criterion standard measure of crowding. The objective was to conduct a systematic review of crowding measures and compare them in conceptual foundation and validity. METHODS: This was a systematic, comprehensive review of four medical and health care citation databases to identify studies related to crowding in the emergency department (ED). Publications that "describe the theory, development, implementation, evaluation, or any other aspect of a 'crowding measurement/definition' instrument (qualitative or quantitative)" were included. A "measurement/definition" instrument is anything that assigns a value to the phenomenon of crowding in the ED. Data collected from papers meeting inclusion criteria were: study design, objective, crowding measure, and evidence of validity. All measures were categorized into five measure types (clinician opinion, input factors, throughput factors, output factors, and multidimensional scales). All measures were then indexed to six validation criteria (clinician opinion, ambulance diversion, left without being seen (LWBS), times to care, forecasting or predictions of future crowding, and other). RESULTS: There were 2,660 papers identified by databases; 46 of these papers met inclusion criteria, were original research studies, and were abstracted by reviewers. A total of 71 unique crowding measures were identified. The least commonly used type of crowding measure was clinician opinion, and the most commonly used were numerical counts (number or percentage) of patients and process times associated with patient care. Many measures had moderate to good correlation with validation criteria. CONCLUSIONS: Time intervals and patient counts are emerging as the most promising tools for measuring flow and nonflow (i.e., crowding), respectively. Standardized definitions of time intervals (flow) and numerical counts (nonflow) will assist with validation of these metrics across multiple sites and clarify which options emerge as the metrics of choice in this "crowded" field of measures.