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The need is growing to create medical big data based on the electronic health records collected from different hospitals. Errors for sure occur and how to correct them should be explored.Electronic health records of 9,197,817 patients and 53,081,148 visits, totaling about 500 million records for 2006-2016, were transmitted from eight hospitals into an integrated database. We randomly selected 10% of patients, accumulated the primary keys for their tabulated data, and compared the key numbers in the transmitted data with those of the raw data. Errors were identified based on statistical testing and clinical reasoning.Data were recorded in 1573 tables. Among these, 58 (3.7%) had different key numbers, with the maximum of 16.34/1000. Statistical differences (P 0.05) were found in 34 (58.6%), of which 15 were caused by changes in diagnostic codes, wrong accounts, or modified orders. For the rest, the differences were related to accumulation of hospital visits over time. In the remaining 24 tables (41.4%) without significant differences, three were revised because of incorrect computer programming or wrong accounts. For the rest, the programming was correct and absolute differences were negligible. The applicability was confirmed using the data of 2,730,883 patients and 15,647,468 patient-visits transmitted during 2017-2018, in which 10 (3.5%) tables were corrected.Significant magnitude of inconsistent data does exist during the transmission of big data from diverse sources. Systematic validation is essential. Comparing the number of data tabulated using the primary keys allow us to rapidly identify and correct these scattered errors.

Importance Protocol driven ED observation units (EDOU) have been shown to improve outcomes for patients and payers, however their impact on an entire health system is unknown. Two thirds of US hospitals do not have such units. Objective To determine the impact of a protocol-driven EDOU on health system length of stay, cost, and resource utilization. Methods A retrospective, observational, cross-sectional study of observation patients managed over 25 consecutive months in a four-hospital academic health system. Patients were identified using the “admit to observation” order and limited to adult, emergent / urgent, non-obstetric patients. Data was retrieved from a cost accounting database. The primary study exposure was the setting for observation care which was broken into three discrete groups: EDOUs (n = 3), hospital medicine observation units (HMSOU, n = 2), and a non-observation unit (NOU) bed located anywhere in the hospital. Outcomes included observation-to-inpatient admission rate, length of stay (LoS), total direct cost, and inpatient bed days saved. Unadjusted outcomes were compared, and outcomes were adjusted using multiple study variables. LoS and cost were compared using quantile regressions. Inpatient admit rate was compared using logistic regressions. Results The sample consisted of 48,145 patients who were 57.4% female, 48% Black, 46% White, median age of 58, with some variation in most common diagnoses and payer groups. The median unadjusted outcomes favored EDOU over NOU settings for admission rate (13.1% vs 37.1%), LoS [17.9 vs 35.6 h), and cost ($1279 vs $2022). The adjusted outcomes favored EDOU over NOU settings for admission rates [12.3% (95% CI 9.7–15.3) vs 26.4% (CI 21.3–32.3)], LoS differences [11.1 h (CI 10.6–11.5 h)] and cost differences [$127.5 (CI $105.4 - $149.5)]. Adjusted differences were similar and favored EDOU over HMSOU settings. For the health system, the total adjusted annualized savings of the EDOUs was 10,399 bed days and $1,329,443 in total direct cost per year. Conclusion Within an academic medical center, EDOUs were associated with improved resource utilization and reduced cost. This represents a significant opportunity for hospitals to improve efficiency and contain costs.

Major advances in diagnosis and treatment have emerged for hypertrophic cardiomyopathy (HCM), largely in major tertiary referral centers dedicated to this disease. Whether these therapeutic benefits are confined to patients in such highly selected cohorts, or can be implemented effectively in independent regional or community-based populations is not generally appreciated. We assessed management and clinical outcomes in a non-referral HCM center (n = 214 patients) in Eastern Pennsylvania. Over a 6.0 ± 3.2-year follow-up, the HCM-related mortality rate was 0.1% per year attributed to a single disease-related death, in a 49-year-old man with end-stage heart failure, ineligible for heart transplant. Fifteen patients (7%) with prophylactically placed implantable cardioverter-defibrillators (ICDs) experienced appropriate therapy terminating life-threatening ventricular tachyarrhythmias. In 23 other patients (11%; 5%/year), heart failure due to left ventricular outflow obstruction was reversed by surgical septal myectomy (n = 20) or percutaneous alcohol septal ablation (n = 3). This regional HCM cohort was similar to a comparison tertiary center referral population in terms of HCM-mortality: 0.1%/year vs 0.3%/year (p = 0.3) and ICD therapy (31% vs 16% of primary prevention implants), although more frequently with uncomplicated benign clinical course (62% vs 46%; p0.01). In conclusion, effective contemporary HCM management strategies and outcomes in referral-based HCM centers can be successfully replicated in regional and/or non-referral settings. Therefore, HCM is now a highly treatable disease compatible with normal longevity when assessed in a variety of clinical venues not limited to tertiary centers.

Background: Burnout and distress have a negative impact on nurses and the treatment they provide. Our aim was to measure the prevalence of burnout and distress among nurses in a cardiovascular centre at 2 quaternary referral hospitals in Canada, and compare these outcomes to those for nurses at academic health science centres (AHSCs) in the United States. Methods: We conducted a survey of nurses practising in a cardiovascular centre at 2 quaternary referral hospitals in Toronto, Ontario, between Nov. 27, 2018, and Jan. 31, 2019. The survey tool included the Well-Being Index (WBI), which measures fatigue, depression, burnout, anxiety or stress, mental and physical quality of life, work–life integration, meaning in work and distress; a score of 2 or higher on the WBI indicated high distress. We also evaluated nurses’ perception of the adequacy of staffing levels and of fair treatment in the workplace, and satisfaction with the electronic health record. We carried out standard univariate statistical comparisons using the χ2, Fisher exact or Kruskal–Wallis test as appropriate to perform univariate comparisons in the sample of respondents. We assessed the relation between a WBI score of 2 or higher and demographic characteristics. We compared univariate associations among WBI data for nurses at AHSCs in the US who completed the WBI to responses from our participants. Results: The response rate to the survey was 49.1% (242/493). Of the 242 respondents, 188 (77.7%) reported burnout in the previous month; 189 (78.1%) had a WBI score of 2 or higher, and 132 (54.5%) had a score of 4 or higher (indicative of severe distress). Ordinal multivariable analysis showed that lower WBI scores were associated with satisfaction with staffing levels (odds ratio [OR] 0.33, 95% confidence interval [CI] 0.16–0.69) and the perception of fair treatment in the workplace (OR 0.41, 95% CI 0.23–0.74). Higher proportions of our respondents than nurses at AHSCs in the US reported burnout (77.7% v. 60.5%, p < 0.001) and had a WBI score of 2 or higher (78.1% v. 57.0%) or 4 or higher (54.5% v. 32.0%) (both p < 0.001). Interpretation: Although levels of burnout and distress were high among nurses, their perceptions of adequate staffing and fair treatment were associated with lower distress. Addressing inadequate staffing and unfair treatment may decrease burnout and other dimensions of distress among nurses, and improve their work experience and patient outcomes.

BACKGROUND Burnout and distress have a negative impact on nurses and the treatment they provide. Our aim was to measure the prevalence of burnout and distress among nurses in a cardiovascular centre at 2 quaternary referral hospitals in Canada, and compare these outcomes to those for nurses at academic health science centres (AHSCs) in the United States. METHODS We conducted a survey of nurses practising in a cardiovascular centre at 2 quaternary referral hospitals in Toronto, Ontario, between Nov. 27, 2018, and Jan. 31, 2019. The survey tool included the Well-Being Index (WBI), which measures fatigue, depression, burnout, anxiety or stress, mental and physical quality of life, work-life integration, meaning in work and distress; a score of 2 or higher on the WBI indicated high distress. We also evaluated nurses' perception of the adequacy of staffing levels and of fair treatment in the workplace, and satisfaction with the electronic health record. We carried out standard univariate statistical comparisons using the χ2, Fisher exact or Kruskal-Wallis test as appropriate to perform univariate comparisons in the sample of respondents. We assessed the relation between a WBI score of 2 or higher and demographic characteristics. We compared univariate associations among WBI data for nurses at AHSCs in the US who completed the WBI to responses from our participants. RESULTS The response rate to the survey was 49.1% (242/493). Of the 242 respondents, 188 (77.7%) reported burnout in the previous month; 189 (78.1%) had a WBI score of 2 or higher, and 132 (54.5%) had a score of 4 or higher (indicative of severe distress). Ordinal multivariable analysis showed that lower WBI scores were associated with satisfaction with staffing levels (odds ratio [OR] 0.33, 95% confidence interval [CI] 0.16-0.69) and the perception of fair treatment in the workplace (OR 0.41, 95% CI 0.23-0.74). Higher proportions of our respondents than nurses at AHSCs in the US reported burnout (77.7% v. 60.5%, p < 0.001) and had a WBI score of 2 or higher (78.1% v. 57.0%) or 4 or higher (54.5% v. 32.0%) (both p < 0.001). INTERPRETATION Although levels of burnout and distress were high among nurses, their perceptions of adequate staffing and fair treatment were associated with lower distress. Addressing inadequate staffing and unfair treatment may decrease burnout and other dimensions of distress among nurses, and improve their work experience and patient outcomes.

Background Burnout and distress negatively affect the well-being of health care professionals and the treatment they provide. Our aim was to measure the prevalence of burnout and distress among allied health care staff at a cardiovascular centre of a quaternary hospital network in Canada, and compare outcomes to those for nonphysician employees in the United States. Methods We conducted a survey of allied health care staff, including physical, respiratory and occupational therapists, pharmacists, social workers, dietitians and speech-language pathologists, in a cardiovascular centre at 2 quaternary referral hospitals in Toronto, Ontario, between Nov. 27, 2018, and Jan. 31, 2019. The survey tool included the Well-Being Index (WBI), which measures fatigue, depression, burnout, anxiety or stress, quality of life, work-life integration, meaning in work and overall distress; a score of 2 or higher indicated high distress. We carried out standard univariate statistical comparisons using the χ2, Fisher exact or Kruskal-Wallis test as appropriate to perform univariate comparisons in the sample of respondents. We assessed the relation between a WBI score of 2 or higher and demographic characteristics. We compared univariate associations among WBI data for nonphysician employees in the US who completed the WBI to responses from our participants. Results The response rate to the survey was 86% (45/52). Thirty-three respondents (73%) reported experiencing burnout in the previous month, and 31 (69%) reported emotional problems. Compared to respondents who perceived fair treatment in the workplace, those who perceived unfair treatment (20 [44%]) were more likely to report emotional problems (17 [85%] v. 13 [54%], p = 0.05), to worry that work was hardening them emotionally (15 [75%] v. 8 [33%], p = 0.008), and to feel down, depressed or hopeless (12 [60%] v. 4 [17%], p = 0.005). Twenty-five respondents (56%) and 13 respondents (29%) reported WBI scores consistent with high (≥ 2) or severe (≥ 5) distress, respectively. Respondents were more likely to have a high WBI score if they perceived unfair treatment or inadequate staffing levels. Our respondents had a higher prevalence of burnout (73.3% v. 53.6%, p = 0.008) and a higher average WBI score (2.6 [SD 2.8] v. 1.7 [SD 2.6], p = 0.05) than 9096 nonphysician employees in the US. Interpretation The prevalence of burnout, emotional problems and distress was high among allied health care staff. Fair treatment in the workplace and adequate staffing may lower distress levels and improve the work experience of these health care professionals.

Coronavirus disease-2019 (COVID-19) has become a pandemic disease globally. The First Affiliated Hospital of Chengdu Medical College has adopted telestroke to make stroke care accessible in remote areas. During the period January 2020 to March 2020, there was no COVID-19 case reported in our stroke center. A significant reduction of stroke admission was observed between the ischemic stroke group (235 vs. 588 cases) and the intracerebral hemorrhage group (136 vs. 150 cases) when compared with the same period last year (p < 0.001). The mean door-to-needle time (DNT) and door-to-puncture time (DPT) was 62 and 124 min, respectively. Compared to the same period last year, a significant change was observed in DNT (62 ± 12 vs. 47 ± 8 min, p = 0.019) but not in DPT (124 ± 58 vs. 135 ± 23 min, p = 0.682). A total of 46 telestroke consultations were received from network hospitals. Telestroke management in the central hospital was performed on 17 patients. Of them, 3 (17.6%) patients had brain hernia and died in hospital and 8 (47.1%) patients were able to ambulation at discharge and had a modified Rankin Scale of 0–2 at 3 months. The COVID-19 pandemic impacted stroke care significantly in our hospital, including prehospital and in-hospital settings, resulting in a significant drop in acute ischemic stroke admissions and a delay in DNT. The construction of a telestroke network enabled us to extend health-care resources and make stroke care accessible in remote areas. Stroke education and public awareness should be reinforced during the COVID-19 pandemic.

Objective Spontaneous spinal cerebrospinal fluid (CSF) leaks are rare and challenging to diagnose and treat. Patients may present to a variety of physicians, and many patients are often referred to a specialized center with a dedicated spinal CSF leak program and expertise in this condition. To our knowledge, there are no reported publications on how to create such a program. Conclusion In this article, we describe the specific steps we took to develop a spinal CSF leak program, which we have implemented over a multihospital network.

Purposes/objectives In 2013, our multihospital system began the process to integrate and standardize clinical nurse specialist (CNS) practice. The goal was to standardize work and to increase collaboration as part of one system. Description of the project/program An overall job description was established to provide a framework inclusive of the broad areas of practice. Clinical nurse specialists were positioned to support medical-surgical, critical care, or women and children's services offered at community-based hospitals. Main campus and community-based CNSs led significant system integration efforts such as the standardization of nursing policies and procedures across the health system. System CNSs were created to address the needs of specialties common to all hospitals. As an example, a system CNS collaborated with the main campus and community-based CNSs to improve the delirium screening process. Outcome Clinical nurse specialists across the system have been integrated into a single team and report to 1 central director. Efforts to leverage expertise included the creation of a CNS-led practice council, increased communication via regular departmental meetings, and the sharing of resources using electronic platforms. There is now a CNS at hospitals that previously did not have one. The group values the structure and opportunities it provides as evidenced by favorable engagement surveys. Conclusion Our integration efforts improved collaboration and could be modified to benefit other care settings.

Purpose Standardization of magnetic resonance imaging protocols is important to achieve reproducible and effective outcomes across a large volume of patient examinations. It also ensures a consensus-driven approach to imaging, while reducing inefficient workflow practices. This article details our approach and experience with implementing systematic methods to address obstacles, and instituting a protocol strategy from development to installation to feedback. Methods A collaborative planning and implementation strategy was derived to address and centralize protocol standardization for 25 MRI systems across 14 imaging centers. In addition to establishing radiologist-lead working groups to define clinical need for each division, we enlisted MR physicists to work with sites to outline system capability and recommend best practices for each protocol method. The strategy also involved protocol alternatives due to patient type, and steps to ensure image quality feedback mechanisms. Results We found that a collaborative team of radiologists, physicists, and technologists is vital for creating structured and categorized protocols that balances clinical need and accepted standards, with system technical capability and exam time limitations. A formalized protocol document and numbering system was created to allow efficient order-to-protocol assignment and selection. Consideration for other variables, such as patient type, user education, and automated tasks, further extend protocol usability and standardization in clinical practice. Conclusions MRI protocol standardization is a significant challenge within a large institution, which requires ongoing oversight and improvement. An organized committee of stakeholders, incorporating clinical, technical, and site-specific expertise, is an important first step to understand the current state and direct standardization goals.

This article examines the relationship between hospital profitability and efficiency. A cross-section of 1317 U.S. metropolitan, acute care, not-for-profit hospitals for the year 2015 was employed. We use a frontier method, stochastic frontier analysis, to estimate hospital efficiency. Total margin and operating margin were used as profit variables in OLS regressions that were corrected for heteroskedacity. In addition to estimated efficiency, control variables for internal and external correlates of profitability were included in the regression models. We found that more efficient hospitals were also more profitable. The results show a positive relationship between profitability and size, concentration of output, occupancy rate and membership in a multi-hospital system. An inverse relationship was found between profits and academic medical centers, average length of stay, location in a Medicaid expansion state, Medicaid and Medicare share of admissions, and unemployment rate. The results of a Hausman test indicates that efficiency is exogenous in the profit equations. The findings suggest that not-for-profit hospitals will be responsive to incentives for increasing efficiency and use market power to increase surplus to pursue their objectives.

Aims The primary aim of this paper was to outline the processes involved in building the Partners Arthroplasty Registry (PAR), established in April 2016 to capture baseline and outcome data for patients undergoing arthroplasty in a regional healthcare system. A secondary aim was to determine the quality of PAR’s data. A tertiary aim was to report preliminary findings from the registry and contributions to quality improvement initiatives and research up to March 2019. Methods Structured Query Language was used to obtain data relating to patients who underwent total hip or knee arthroplasty (THA and TKA) from the hospital network’s electronic medical record (EMR) system to be included in the PAR. Data were stored in a secure database and visualized in dashboards. Quality assurance of PAR data was performed by review of the medical records. Capture rate was determined by comparing two months of PAR data with operating room schedules. Linear and binary logistic regression models were constructed to determine if length of stay (LOS), discharge to a care home, and readmission rates improved between 2016 and 2019. Results The PAR captured 16,163 THAs and TKAs between April 2016 and March 2019, performed in seven hospitals by 110 surgeons. Manual comparison to operating schedules showed a 100% capture rate. Review of the records was performed for 2,603 random operations; 2,298 (88.3%) had complete and accurate data. The PAR provided the data for three abstracts presented at international conferences and has led to preoperative mental health treatment as a quality improvement initiative in the participating institutions. For primary THA and TKA surgeries, the LOS decreased significantly (p < 0.001) and the rate of home discharge increased significantly (p < 0.001) between 2016 and 2019. Readmission rates did not correlated with the date of surgery (p = 0.953). Conclusion The PAR has high rates of coverage (the number of patients treated within the Partners healthcare network) and data completion and can be used for both research purposes and quality improvement. The same method of creating a registry that was used in the PAR can be applied to hospitals using similar EMR systems. Cite this article: Bone Joint J 2020;102-B(7 Supple B):90–98.

Background We previously reported fetomaternal hemorrhage (FMH) in 1/9160 births, and only one neonatal death from FMH among 219,853 births. Recent reports indicate FMH is not uncommon among stillbirths. Consequently, we speculated we were missing cases among early neonatal deaths. We began a new FMH initiative to determine the current incidence. Methods We analyzed births from 2011 to 2020 where FMH was diagnosed. We also evaluated potential cases among neonates receiving an emergent transfusion just after birth, whose mothers were not tested for FMH. Results Among 297,403 births, 1375 mothers were tested for FMH (1/216 births). Fourteen percent tested positive (1/1599 births). Of those, we found 25 with clinical and laboratory evidence of FMH adversely affecting the neonate. Twenty-one received one or more emergency transfusions on the day of birth; all but two lived. We found 17 others who received an emergency transfusion on the day of birth where FMH was not tested for, but was likely; eight of those died. The 42 severe (proven + probable) cases equate to 1/7081 births. We judged that 10 of the 42 had an acute FMH, and in the others it likely had more than a day before birth. Conclusions We estimate that we fail to diagnose >40% of our severe FMH cases. Needed improvements include (1) education to request maternal FMH testing when neonates are born anemic, (2) education on false-negative FMH tests, and (3) improved FMH communications between neonatology, obstetrics, and blood bank.

Introduction In 1999 an inclusive trauma system was initiated in the Netherlands and a nationwide trauma registry, including all admitted trauma patients to every hospital, was started. The Dutch trauma system is run by trauma surgeons who treat both the truncal (visceral) and extremity injuries (fractures). Materials and Methods In this comprehensive review based on previous published studies, data over the past 20 years from the central region of the Netherlands (Utrecht) was evaluated. Results It is demonstrated that the initiation of the trauma systems and the governance by the trauma surgeons led to a region-wide mortality reduction of 50% and a mortality reduction for the most severely injured of 75% in the level 1 trauma centre. Furthermore, major improvements were found in terms of efficiency, demonstrating the quality of the current system and its constructs such as the type of surgeon. Due to the major reduction in mortality over the past few years, the emphasis of trauma care evaluation shifts towards functional outcome of severely injured patients. For the upcoming years, centralisation of severely injured patients should also aim at the balance between skills in primary resuscitation and surgical stabilization versus longitudinal surgical involvement. Conclusion Further centralisation to a limited number of level 1 trauma centres in the Netherlands is necessary to consolidate experience and knowledge for the trauma surgeon. The future trauma surgeon, as specialist for injured patients, should be able to provide the vast majority of trauma care in this system. For the remaining part, intramural, regional and national collaboration is essential

Multisite nursing research can be a challenging endeavor. A unique partnership between 5 clinical sites and a national research center of a healthcare technology organization led to the successful implementation of a multisite study. Strategies for success, obstacles encountered, benefits, implications for the Magnet journey, and leadership are discussed.

The coronavirus disease 2019 (COVID-19) pandemic has led to changes in health care utilization for different acute cardiovascular diseases. Whether hospitalization rates and in-hospital mortality were affected by the pandemic in patients with acute symptomatic heart failure (HF) was investigated in this study.Administrative data provided by 67 German Helios hospitals were examined for patients with a main discharge diagnosis of HF using ICD codes. Urgent hospital admissions per day were compared for a study period (13 March-21 May 2020) with control intervals in 2020 (1 January-12 March) and 2019 (13 March-21 May), resulting in a total of 13 484 patients excluding all patients with laboratory-proven COVID-19 infection. Incidence rate ratios (IRR) were calculated using Poisson regression. Generalized linear mixed models were used for univariable and multivariable analysis to identify predictors of in-hospital mortality. The number of admissions per day was lower in the study period compared to the same year [IRR 0.69, 95% confidence interval (CI) 0.67-0.73, P 0.01] and the previous year control group (IRR 0.73, 95% CI 0.70-0.76, P 0.01). Age was similar throughout the intervals, but case severity increased in terms of distribution within New York Heart Association (NYHA) classes and comorbidities. Within the study period, 30-day rates for urgent hospital readmissions were higher compared to the same year but not the previous year control group. In-hospital mortality was 7.3% in the study period, 6.1% in the same year (P = 0.03) and 6.0% in the previous year control group (P = 0.02). In multivariable analysis, age, NYHA class and other predictors of fatal outcome were identified but hospitalization during the study period was not independently associated with mortality.Our data showed a significant reduction of urgent hospital admissions for HF with increased case severity and concomitant in-hospital mortality during the COVID-19 pandemic in Germany. Identifying causes of reduced inpatient treatment rates is essential for the understanding and valuation with regard to future optimal management of patients with HF.

Knowing the areas of service, actions, and parameters that can influence patient perception about a service provided can help hospital executives and healthcare workers to devise improvement plans, leading to higher patient satisfaction.To identify inpatient satisfaction determinants, assess their relationships with hospital variables, and improve patient satisfaction through interventions.We studied the inpatient population of an eight-hospital tertiary medical center in 2015. The satisfaction determinants were based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey answers and included clinical and organizational variables.Interventions began at the end of 2016 included bedside care coordination rounds (BCCR), medications best practices alert (BPA), connect transitions post-discharge calls (CONNECT Transitions) and a framework for provider-patient interactions called AIDET (Acknowledge, Introduce, Duration, Explain, and Thank). Substantial impact upon patient satisfaction was observed after the introduction of these interventions.Three groups were identified: 1. high satisfaction, which correlated with race, surgery, and cancer care; 2. low satisfaction, correlated with elderly, emergency room, intensive care unit, chronic obstructive pulmonary disease, and vascular diseases; and 3. neutral, correlated with hospital-acquired complications, several diagnostic procedures, and medical care delay. Significant improvements in the 3 groups were achieved with interventions that optimize care provider interactions with patients and their families.Based on the HCAHPS-based analysis, we implemented new measures and programs for addressing coordination of care, improving patient safety, reducing the length of stay, and ultimately improving patient satisfaction.

BACKGROUND: The institution-wide response of the University of California San Diego Health system to the 2019 novel coronavirus disease (COVID-19) pandemic was founded on rapid development of in-house testing capacity, optimization of personal protective equipment usage, expansion of intensive care unit capacity, development of analytic dashboards for monitoring of institutional status, and implementation of an operating room (OR) triage plan that postponed nonessential/elective procedures. We analyzed the impact of this triage plan on the only academic neurosurgery center in San Diego County, California, USA. METHODS: We conducted a de-identified retrospective review of all operative cases and procedures performed by the Department of Neurosurgery from November 24, 2019, through July 6, 2020, a 226-day period. Statistical analysis involved 2-sample z tests assessing daily case totals over the 113-day periods before and after implementation of the OR triage plan on March 16, 2020. RESULTS: The neurosurgical service performed 1429 surgical and interventional radiologic procedures over the study period. There was no statistically significant difference in mean number of daily total cases in the pre-versus post-OR triage plan periods (6.9 vs. 5.8 mean daily cases; 1-tail P = 0.050, 2-tail P = 0.101), a trend reflected by nearly every category of neurosurgical cases. CONCLUSIONS: During the COVID-19 pandemic, the University of California San Diego Department of Neurosurgery maintained an operative volume that was only modestly diminished and continued to meet the essential neurosurgical needs of a large population. Lessons from our experience can guide other departments as they triage neurosurgical cases to meet community needs.

Though much of routine healthcare pauses in a public health emergency, childbirth continues uninterrupted. Crises like COVID-19 put incredible strains on healthcare systems and require strategic planning, flexible adaptability, clear communication, and judicious resource allocation. Experiences from obstetric units affected by COVID-19 highlight the importance of developing new teams and workflows to ensure patient and healthcare worker safety. Additionally, adapting a strategy that combines units and staff from different areas and hospitals can allow for synergistic opportunities to provision care appropriately to manage a structure and workforce at maximum capacity.

The COVID-19 pandemic has led to the rapid expansion of telehealth services as healthcare organizations aim to mitigate community transmission while providing safe patient care. As technology adoption rapidly increases, operational telehealth teams must maintain awareness of critical information, such as patient volumes and wait times, patient and provider experience, and telehealth platform performance. Using a model of situation awareness as a conceptual foundation and a user-centered design approach we describe our process for rapidly developing and disseminating dashboard visualizations to support telehealth operations. We used a 5-step process to gain domain knowledge, identify user needs, identify data sources, design and develop visualizations, and iteratively refine these visualizations. Through this process we identified 3 distinct stakeholder groups and designed and developed visualization dashboards to meet their needs. Feedback from users demonstrated the dashboard’s support situation awareness and informed important operational decisions. Lessons learned are shared to provide other organizations with insights from our process.

Introduction The COVID‐19 pandemic caused by the severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) virus has altered the health care environment for the management of head and neck cancers. The purpose of these guidelines is to provide direction during the pandemic for rational Head and Neck Cancer management in order to achieve a medically and ethically appropriate balance of risks and benefits. Methods Creation of consensus document. Results The process yielded a consensus statement among a wide range of practitioners involved in the management of patients with head and neck cancer in a multihospital tertiary care health system. Conclusions These guidelines support an ethical approach for the management of head and neck cancers during the COVID‐19 epidemic consistent with both the local standard of care as well as the head and neck oncological literature.

Background Providing adequate psychiatry consultation capacity on a 24/7 basis is an intrinsic challenge throughout many multihospital health care systems. At present, implementation research has not adequately defined the effectiveness and feasibility of a centralized telepsychiatry consultation service within a multihospital health care system. Objective To demonstrate feasibility of a hub and spoke model for provision of inpatient consult telepsychiatry service from an academic medical center to 2 affiliated regional hospital sites, to reduce patient wait time, and to develop best practice guidelines for telepsychiatry consultations to the acutely medically ill. Methods The implementation, interprofessional workflow, process of triage, and provider satisfaction were described from the first 13 months of the service. Results This pilot study resulted in 557 completed telepsychiatry consults over the course of 13 months from 2018 to 2019. A range of psychiatric conditions commonly encountered by consultation-liaison services were diagnosed and treated through the teleconferencing modality. The most common barriers to successful use of telepsychiatry were defined for the 20% of consult requests that were retriaged to face-to-face evaluation. The average patient wait time from consult request to initial consultation was reduced from >24 hours to 92 minutes. Conclusions This study demonstrated the feasibility of a centralized telepsychiatry hub to improve delivery of psychiatry consultation within a multihospital system with an overall reduction in patient wait time. This work may serve as a model for further design innovation across many health care settings and new patient subpopulations.

Novel coronavirus disease 2019 is rapidly spreading throughout the New York metropolitan area since its first reported case on March 1, 2020. The state is now the epicenter of coronavirus disease 2019 outbreak in the United States, with 84,735 cases reported as of April 2, 2020. We previously presented an early case series with 7 coronavirus disease 2019–positive pregnant patients, 2 of whom were diagnosed with coronavirus disease 2019 after an initial asymptomatic presentation. We now describe a series of 43 test-positive cases of coronavirus disease 2019 presenting to an affiliated pair of New York City hospitals for more than 2 weeks, from March 13, 2020, to March 27, 2020. A total of 14 patients (32.6%) presented without any coronavirus disease 2019–associated viral symptoms and were identified after they developed symptoms during admission or after the implementation of universal testing for all obstetric admissions on March 22. Among them, 10 patients (71.4%) developed symptoms of coronavirus disease 2019 over the course of their delivery admission or early after postpartum discharge. Of the other 29 patients (67.4%) who presented with symptomatic coronavirus disease 2019, 3 women ultimately required antenatal admission for viral symptoms, and another patient re-presented with worsening respiratory status requiring oxygen supplementation 6 days postpartum after a successful labor induction. There were no confirmed cases of coronavirus disease 2019 detected in neonates upon initial testing on the first day of life. Based on coronavirus disease 2019 disease severity characteristics by Wu and McGoogan, 37 women (86%) exhibited mild disease, 4 (9.3%) severe disease, and 2 (4.7%) critical disease; these percentages are similar to those described in nonpregnant adults with coronavirus disease 2019 (about 80% mild, 15% severe, and 5% critical disease).

Local multihospital systems (LMSs) commonly struggle to effectively coordinate across system members. Although a recent taxonomy of LMSs found the majority of systems to display lower levels of differentiation, integration, and coordination, some categories of LMS forms exhibited higher levels of integration and coordination.This study examines organizational and environmental factors associated with LMS forms displaying higher levels of integration and coordination.Applying a multitheoretical framework and drawing from sources including the American Hospital Association Annual Survey, Intellimed databases, and primary data collected from LMS communications, descriptive and multinomial logistic regression analyses were conducted to examine the association between LMS forms and varied organizational and environmental characteristics among LMSs in Florida, Maryland, Nevada, Texas, Virginia, and Washington.The results of analysis of variance, Games-Howell, and Fisher's exact tests identified significant relationships between each of the five LMS categories and varying market, competitive, organizational, and operational factors. A multinomial logistic regression analysis also distinguished the three most common LMS forms according to organizational and environmental factors.Recognizing the varied degrees of integration and coordination across LMSs today, the results point to several factors that may explain such variation, including market size and resources, local competitors and their forms, organizational size and ownership, patient complexity, and regulatory restrictions.With the continued promotion and development of innovative health care reform models and with the progressing expansion of care into outpatient sites and diverse settings, LMSs will continue to face greater pressure to integrate and coordinate services throughout the continuum of care across system components and service locations. Navigating the challenges of effective coordination requires administrators and policymakers to be cognizant of the organizational and environmental factors that may hinder or fuel coordination efforts across system components in local markets.

The model analyzes the positive moderating role of absorptive capacity (ACAP) in the innovative outcomes of the firms. It focuses on ACAP as a moderating variable of the innovative efforts that firms develop or have the chance of incorporating from outside and not just as an antecedent of the innovation results. The empirical evidence collected comes from a study conducted on 189 SMEs working in IT services in Argentina and the results prove the main hypothesis of how ACAP is a positive moderating factor of the innovative effort of firms, even in the case of the connections created by their the participation in international networks not having a high correlation. Some suggestions for policymaker managers and future lines of research are provided.

The success of our hospital-based Palliative Care program stimulated requests to duplicate the program across the health system continuum of care.To develop a model of care focused on a high-need, high-cost population that could be implemented across all care settings, including hospitals and patients' homes.To fiscally support program expansion from hospital to home, we conducted a retrospective cost analysis for home-based Palliative Care (HBPC)-enrolled patients with continuous claims months before program enrollment through date of death. The HBPC enrollees were evaluated against a cohort group of CMS (Centers for MedicareMedicaid Service) and Medicare Advantage patients who did not participate in the HBPC program (n = 3135). Twenty-one months of claims leading up to the date of death were evaluated for both populations. The analysis was designed to test whether Palliative Care patients demonstrated less overall claims expense and service utilization in the same periods as patients without Palliative Care. Claim months were grouped into three-month clusters for evaluation and statistical testing of per member per month utilization and cost.Overall, HBPC patients demonstrated significantly less service utilization and cost in the months leading up to death. Cost differences were primarily driven by clear cost divergence in the last three months of life [$9,843 (PC) vs. $27,530 (C)]. Our program grew from a hospital-based program to include the establishment of a home-based program.Palliative Care programs can successfully expand outside hospital walls to serve a high need/high-cost patient population.

We study the impact of specialization on the operational efficiency of a multi-hospital system. The mixed outcomes of recently increasing hospital mergers and system re-configuration initiatives have raised the importance of studying such organizational changes from all the relevant perspectives. We consider two configuration scenarios for a multi-hospital system. The first scenario assumes that all the hospitals in the system are general, which implies they can provide care to all types of patients. In the alternative configuration, we specialize each hospital in certain level of care, which means they serve only specific types of patients. By considering an extensive number of possible settings for a multi-hospital system, we characterize the situations in which one scenario outperforms the other in terms of extending access of patients to care. Our results show that whenever the percent of patients with shorter length of stay in the system increases, specialization of healthcare services can maximize the accessibility of care. Also, if the patient load is balanced between all hospitals in the system, it seems more likely that all hospitals benefit from specialization. We conclude that the strategic decision of designing a multi-hospital system requires careful consideration of patient mix among arrivals, relative length of stay of patients, and distribution of patient load between hospitals.

Myeloproliferative neoplasms arise from hematopoietic stem cells with somatically altered tyrosine kinase signaling. Classification of myeloproliferative neoplasms is based on hematologic, histopathologic and molecular characteristics including the presence of the BCR-ABL1 and JAK2 V617F. Although thought to be mutually exclusive, a number of cases with co-occurring BCR-ABL1 and JAK2 V617F have been identified. To characterize the clinicopathologic features of myeloproliferative neoplasms with concomitant BCR-ABL1 and JAK2 V617F, and define the frequency of co-occurrence, we conducted a retrospective multi-institutional study. Cases were identified using a search of electronic databases over a decade at six major institutions. Of 1570 patients who were tested for both BCR-ABL1 and JAK2 V617F, six were positive for both. An additional five patients were identified via clinical records providing a total of 11 cases for detailed evaluation. For each case, clinical variables, hematologic and genetic data, and bone marrow histomorphologic features were analyzed. The sequence of identification of the genetic abnormalities varied: five patients were initially diagnosed with a JAK2 V617F+ myeloproliferative neoplasm, one patient initially had BCR-ABL1+ chronic myeloid leukemia, while both alterations were identified simultaneously in five patients. Classification of the BCR-ABL1-negative myeloproliferative neoplasms varied, and in some cases, features only became apparent following tyrosine kinase inhibitor therapy. Seven of the 11 patients showed myelofibrosis, in some cases before identification of the second genetic alteration. Our data, reflecting the largest reported study comprehensively detailing clinicopathologic features and response to therapy, show that the co-occurrence of BCR-ABL1 and JAK2 V617F is rare, with an estimated frequency of 0.4%, and most often reflects two distinct ('composite') myeloproliferative neoplasms. Although uncommon, it is important to be aware of this potentially confounding genetic combination, lest these features be misinterpreted to reflect resistance to therapy or disease progression, considerations that could lead to inappropriate management.

Surgical site infections, readmissions, and extended hospital stays are risks for patients undergoing colon surgeries. These procedures are often urgent, and patients may have multiple comorbidities. Preoperative and postoperative steps to reduce the number of complications provide substantial benefits clinically, economically, and psychologically. We used a multidisciplinary, collaborative approach to identify best practices when developing and implementing a standardized approach to the management of patients undergoing elective colon surgery. Interventions included nutrition supplements and preoperative and postoperative protocols. Our management project showed a 74.6% reduction in readmissions, a 22.73% reduction in length of stay, an 85% reduction in colon surgical site infections measured by incidence (84.5% reduction) and standard infection ratio (54.55% reduction), and 95% compliance with the use of both order sets during an 18-month period. Applying standardized order sets for assessing and addressing patient comorbidities before colorectal surgery can result in a substantial and sustainable reduction in complications.

Background Lean practices have been widely used by health care organizations to meet efficiency, performance and quality improvement needs. The lean health care literature shows that the effective implementation of lean requires a holistic system-wide approach. However, there is still limited evidence on what drives effective system-wide lean implementation in health care. The existing literature suggests that a deeper understanding of how lean interventions interact with the organizational context is necessary to identify the critical variables to successfully sustain system-wide lean strategies. Purpose and methodology: A multiple case study of three Italian hospitals is conducted with the aim to explore the organizational conditions that are relevant for an effective system-wide lean implementation. A conceptual framework, built on socio-technical system schemas, is used to guide data collection and analysis. Findings: The analysis points out the importance to support lean implementation with an integrated and coordinated strategy involving the social, technical, and external components of the overall hospital system.

Lessons learned from the creation of a multihospital health-system formulary management and pharmacy and therapeutics (PT) committee are described.A health system can create and implement a multihospital system formulary and PT committee to provide evidence-based medications for ideal healthcare. The formulary and PT process should be multidisciplinary and include adequate representation from system hospitals. The aim of a system formulary and PT committee is standardization; however, the system should allow flexibility for differences. Key points for a successful multihospital system formulary and PT committee are patience, collaboration, resilience, and communication. When establishing a multihospital health-system formulary and PT committee, the needs of individual hospitals are crucial. A designated member of the pharmacy department needs to centrally coordinate and manage formulary requests, medication reviews and monographs, meeting agendas and minutes, and a summary of decisions for implementation. It is imperative to create a timeline for formulary reviews to set expectations, as well as a process for formulary appeals. Collaboration across the various hospitals is critical for successful formulary standardization. When implementing a health-system PT committee or standardizing a formulary system, it is important to be patient and give local sites time to make practice changes. Evidence-based data and rationale must be provided to all sites to support formulary changes. Finally, there must be multidisciplinary collaboration.There are several options for formulary structures and PT committees in a health system. Potential strengths and barriers should be evaluated before selecting a formulary management process.

Purpose Challenges and opportunities in managing pharmacy-related technology in a multihospital health system are reviewed. Summary With electronic medical record (EMR) implementations, pharmacy technology deployments, and increased numbers of hospitals merging into single health systems, opportunities and challenges for pharmacy informatics (PI) teams have grown. Pharmacy leaders must consider the implications of using technology in a multihospital health-system environment, as well as the impact of the health system’s organizational structures on technology implementations and dedicated support teams. Common challenges in achieving EMR and other technology implementation and standardization initiatives in multihospital health systems include harmonization of practices across hospitals of various sizes and types and issues of platform compatibility and interoperability. PI teams must collaborate with information technology teams at the system level to identify practical strategies for making the best use of available resources to implement pharmacy automation and software to help pharmacists continue to provide safe and effective patient care. The organizational structures that affect informatics teams, pharmacy integration and standardization initiatives, formulary management practices, data management and analytics, and clinical decision support systems all must be areas of focus. Conclusion An integrated pharmacy enterprise can be well positioned to leverage operational efficiencies gained from appropriate use of technology to enhance patient care. Careful attention must be paid to the manner in which these systems are designed, implemented, and managed in order to make the best use of the technological resources used by the health system.

Primary care physicians (PCPs) experience differential postdischarge access to electronic health records, depending upon affiliation with the discharging hospital's health network. To better understand whether this affiliation impacts discharge communication preferences, we surveyed a convenience sample of PCPs in and out of our hospital's health network. We also surveyed hospitalists and compared PCPs' and hospitalists' responses. We found that PCP discharge communication preferences differed by hospital health network affiliation. In addition, PCPs and hospitalists reported different expectations of responsibility for pending laboratory test follow-up. More inclusive communication strategies and standardization of responsibility for pending laboratory results may improve discharge communication quality.