Trends in Utilization of Electronic Consultations Associated With Patient Payer and Language Among US Academic Medical Centers During the COVID-19 Pandemic.

Importance: Electronic consultations (eConsultations) are increasingly used to obtain specialist guidance, avoiding unnecessary face-to-face patient visits for certain clinical questions. During the COVID-19 pandemic, when in-person care was limited, eConsultations may have helped clinicians obtain specialist input to guide patient care. Objective: To understand how the use of eConsultations changed during the COVID-19 pandemic and whether trends in eConsultation utilization differed based on patient's payer and primary language. Design, Setting, and Participants: This retrospective cohort study was conducted at 6 academic medical centers in the United States, all participating in the Association of American Colleges Coordinating Optimal Referral Experiences program. Participants included adult patients who had an outpatient visit, referral, or eConsultation during the study period. Data were analyzed from June 4, 2019, to July 28, 2020. Main Outcomes and Measures: The primary outcome was the eConsultation proportion of specialty contact, defined as the number of completed eConsultations divided by the sum of the number of completed eConsultations and specialty referrals, expressed as a percentage. eConsultation percentages of specialty contact were further stratified by payer type and language. Payers included commercial, Medicare, Medicaid, self-pay or uninsured, and other. Primary language included English and non-English languages. Results: A total of 14 545 completed eConsultations and 189 776 referrals were included. More eConsultations were completed for English-speaking patients (11 363 eConsultations [95.0%]) than non-English-speaking patients (597 eConsultations [5.0%]). Patients with commercial insurance represented the highest number of completed eConsultations (8848 eConsultations [60.8%]) followed by Medicare (3891 eConsultations [26.8%]), Medicaid (930 eConsultations [6.4%]), other insurance (745 eConsultations [5.1%]), and self-pay or no insurance (131 eConsultations [0.9%]). At the start of the pandemic, across all academic medical centers, the percentage of specialty contact conducted via eConsultation significantly increased by 6.21% (95% CI, 4.97%-7.44%; P < .001). When stratified by payer and language, the percentage of specialty contact conducted via eConsultation significantly increased at the beginning of the pandemic for both English-speaking patients (change, 6.09% (95% CI, 4.82% to 7.37%; P < .001) and non-English-speaking patients (change, 8.48% [95% CI, 5.79% to 11.16%]; P < .001) and for all payers, except self-pay and uninsured patients (change, -0.21% [95% CI, [-1.35% to 0.92%]; P = .70). Conclusions and Relevance: This retrospective cohort study found that eConsultations provided an accessible mechanism for clinicians to receive specialist input when in-person care was limited.

Organisational factors underpinning intra-hospital transfers: a guide for evaluating context in quality improvement.

During intra-hospital transfers, multiple clinicians perform coordinated tasks that leave patients vulnerable to undesirable outcomes. Communication has been established as a challenge to care transitions, but less is known about the organisational complexities within which transfers take place. We performed a qualitative assessment that included various professions to capture a multi-faceted understanding of intra-hospital transfers. Ethnographic observations and semi-structured interviews were conducted with clinicians and staff from the Medical Intensive Care Unit, Emergency Department, and general medicine units at a large, urban, academic, tertiary medical centre. Results highlight the organisational factors that stakeholders view as important for successful transfers: the development, dissemination, and application of protocols; robustness of technology; degree of teamwork; hospital capacity; and the ways in which competing hospital priorities are managed. These factors broaden our understanding of the organisational context of intra-hospital transfers and informed the development of a practical guide that can be used prior to embarking on quality improvement efforts around transitions of care.

A New Tool to Assess Clinician Experience With Patient Care Transitions.

BACKGROUND AND OBJECTIVES: Clinician experience of intrahospital patient care transfers can drive transfer success and safe patient care. Measuring clinician experience can provide insights into opportunities to improve transfer processes that impact patient care. As part of a quality improvement project, we developed a brief survey to gauge clinician experience with patient care transfers that occur within a hospital. METHODS: The survey framework was built upon a previously identified taxonomy of intrahospital transfers that includes categories of transfer activities: disposition, notification, preparation, communication, and coordination. The survey tool was administered twice to physicians, nurses, and other health professionals across a single hospital. Data were analyzed comparing providers sending patients, and those receiving patients. RESULTS: The survey response rate was 33% to 34% across both years. While helpful in demonstrating improving trends in provider experience and engagement with transfer processes, the survey also allowed for differences between the experiences of sending and receiving providers to be revealed. Nurses reported improved preparedness to receive patients and receivers overall reported improved teamwork. Senders' perceptions showed improved trends in all transfer categories. Preliminary data also suggest acceptable reliability across respondent type, item category, and time. Specifically, reliability across sending and receiving clinicians was demonstrated in the categories of timeliness (α = 0.85) and culture (α = 0.72). Responses of sending clinicians were internally consistent within culture (α = 0.82), while responses of receiving clinicians were internally consistent within culture (α = 0.86), timeliness (α = 0.76), notification (α = 0.77), communication (α = 0.73), and teamwork (α = 0.73). CONCLUSIONS: Overall, the survey was feasible to implement and built to optimize content, construct, and response process validity. Survey results drove practical improvement work, such as informing a verbal transfer protocol to improve nursing preparedness to receive patients on general medicine units. As a practical tool, the survey and its results can help hospital administrators to focus on categories of transfer activities that are most problematic for clinicians and to track trends for quality improvement.

Cooperation and conflict in intra-hospital transfers: A qualitative analysis.

Aim: The purpose of this study was to explore the latent conditions of cooperation and conflict in intra-hospital patient transfers (i.e. transfers of patients between units in a hospital). Design: Secondary qualitative analysis of 28 interviews conducted with 29 hospital staff, including physicians (N = 13), nurses (N = 10) and support staff (N = 6) from a single, large academic tertiary hospital in the Northeastern United States. Methods: A two-member multidisciplinary team applied a directed content analysis approach to data collected from semi-structured interviews. Results: Three recurrent themes were generated: (a) patient flow policies created imbalances of power; (b) relationships were helpful to facilitate safe transfers; and (c) method of admission order communication was a source of disagreement. Hospital quality improvement efforts could benefit from a teaming approach to minimize unintentional power imbalances and optimize communicative relationships between units.

Validation of surgical site infection surveillance data in colon procedures reported to the Connecticut Department of Public Health.

A validation study of 692 patients undergoing colon surgery during the fourth quarter of 2012 identified 102 surgical site infections, of which 34% were not reported to the National Healthcare Safety Network. Possible reasons for underreporting included the misinterpretation of the National Healthcare Safety Network surgical site infection definition and variations in case-finding methods. Colon procedure denominator data were also reviewed to determine inaccuracies. Error rates were highest for implant presence (34%), endoscope use (32%), and procedure duration (33%).

Prospective cluster controlled crossover trial to compare the impact of an improved hydrogen peroxide disinfectant and a quaternary ammonium-based disinfectant on surface contamination and health care outcomes.

BACKGROUND: Quaternary ammonium-based (Quat) disinfectants are widely used, but they have disadvantages. METHODS: This was a 12-month prospective cluster controlled crossover trial. On 4 wards, housekeepers performed daily cleaning using a disinfectant containing either 0.5% improved hydrogen peroxide (IHP) or Quat. Each month, 5-8 high-touch surfaces in several patient rooms on each ward were tagged with a fluorescent marker and cultured before and after cleaning. Hand hygiene compliance rates and antimicrobial usage on study wards were obtained from hospital records. Outcomes included aerobic colony counts (ACCs), percent of wiped surfaces yielding no growth after cleaning, and a composite outcome of incidence densities of nosocomial acquisition and infection caused by vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and Clostridium difficile infection. Statistical analysis was performed using χ2 test, Fisher exact test, Welch test, and logistic regression methods. RESULTS: Mean ACCs per surface after cleaning were significantly lower with IHP (14.0) than with Quat (22.2) (P = .003). The proportion of surfaces yielding no growth after cleaning was significantly greater with IHP (240/500; 48%) than with Quat (182/517; 35.2%) (P < .0001). Composite incidence density of nosocomial colonization or infection with IHP (8.0) was lower than with Quat (10.3) (incidence rate ratio, 0.77; P = .068; 95% confidence interval, 0.579-1.029). CONCLUSIONS: Compared with a Quat disinfectant, the IHP disinfectant significantly reduced surface contamination and reduced a composite colonization or infection outcome.

Impact of Room Location on UV-C Irradiance and UV-C Dosage and Antimicrobial Effect Delivered by a Mobile UV-C Light Device.

OBJECTIVE To evaluate ultraviolet C (UV-C) irradiance, UV-C dosage, and antimicrobial effect achieved by a mobile continuous UV-C device. DESIGN Prospective observational study. METHODS We used 6 UV light sensors to determine UV-C irradiance (W/cm2) and UV-C dosage (µWsec/cm2) at various distances from and orientations relative to the UV-C device during 5-minute and 15-minute cycles in an ICU room and a surgical ward room. In both rooms, stainless-steel disks inoculated with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Clostridium difficile spores were placed next to sensors, and UV-C dosages and log10 reductions of target organisms achieved during 5-minute and 15-minute cycles were determined. Mean irradiance and dosage readings were compared using ANOVA. RESULTS Mean UV-C irradiance was nearly 1.0E-03 W/cm2 in direct sight at a distance of 1.3 m (4 ft) from the device but was 1.12E-05 W/cm2 on a horizontal surface in a shaded area 3.3 m (10 ft) from the device (P4 to 1-3 for MRSA, >4 to 1-2 for VRE and >4 to 0 log10 for C. difficile spores, depending on the distance from, and orientation relative to, the device with 5-minute and 15-minute cycles. CONCLUSION UV-C irradiance, dosage, and antimicrobial effect received from a mobile UV-C device varied substantially based on location in a room relative to the UV-C device. Infect Control Hosp Epidemiol 2016;37:667-672.

Validation of the surveillance and reporting of central line-associated bloodstream infection denominator data.

BACKGROUND: While the main focus of validating central line-associated infections (CLABIs) has been applying strict definitions to identify cases, assessing the denominator counts has received less attention. This study evaluates the accuracy of the reporting of CLABSI denominator patient-day (PD) and central line-day (CLD) counts to the National Healthcare Safety Network (NHSN) system in one state. METHODS: The Connecticut Department of Public Health (CT DPH) performed a blinded retrospective chart review on the collection of CLABSI PD and CLD on 9 selected days during the fourth quarter of 2009 from 23 acute care hospitals. RESULTS: Overall, 1,988 intensive care unit patient charts were reviewed. Comparison of hospital and CT DPH counts identified over-reporting by 300 PD (17.2%) and 200 CLD (21.7%) with 17 hospitals (74%) collecting data manually. PD manual collection methods were more accurate than electronic methods (P < .01). For CLD, there was no significant difference in collection method (P > .05). Wednesday PD counts were more accurate than Monday (P < .05) or Saturday (P < .05). For CLD counts, there was no significant difference among the 3 days (P > .05). CONCLUSION: Our results provide some evidence for the prerequisite internal validation of denominator data by hospitals before reporting to the national surveillance system.

"Doing the heavy lifting: health care workers take back their backs".

Health care workers have the highest musculoskeletal disorder prevalence and incidence of any occupational/industry group, and patient handling tasks are so biomechanically demanding that they cannot be made safe through the commonly used, technique-oriented methods such as "back school" training programs. Although there is standard-setting activity for "no-lift" programs in some states, there is still no federal standard. Health care worker unions and nurses' associations have begun to take action through training members in equipment need, use, and acceptance in programs to encourage adoption of no-lifting programs. Acceptance of lifting equipment is increasing due to recognition of the high human and economic costs of MSD, consistent documentation of cost savings from no-lift programs, major improvements in lifting equipment, and shortages of health care staff. An action-oriented training program for health care workers is described that provides knowledge about the 1) Scope of the current problem of back injuries in health care, 2) Costs of injuries, both to workers and to the hospital, 3) Elements of a safe patient-handling program, and 4) Success stories. The program also builds skills through: 1) Hands-on experience with safe lifting equipment, and 2) Assessing organizational and union readiness and planning for action at the workplace.