Optimising after-hours workflow of computed tomography orders in the emergency department

The Impact of Pandemic-Driven Care Redesign on Hospital Efficiency

Purpose

This study aims to identify medical care transformations during the COVID-19 pandemic and to assess the economic efficiency of these care transformations.

Methods

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviewing and Meta-Analysis (PRISMA) guidelines. The databases used in the search protocol included PubMed, RSCI, and Google Scholar.

Results

Ten eligible studies in English and one publication in Russian were identified. In general, the following changes in organization of health care processes since 2020 are observed: hospital at home, telemedicine (physician-to-patient), and the adoption of new information communication technologies within physician-to-physician and physician-to-nurse communication. Earlier trends, such as (a) wider use of electronic devices, (b) adoption of Lean techniques, (c) the incorporation of patient and other customer experience feedback, and (d) the implementation of clinical decision support systems and automation of workflow, tend to be preserved.

Conclusion

The most common changes in hospital care organization and the respective impacts of workflow changes (ie, workflow interventions, redesign, and transformations) on the efficiency of hospital care were summarized and avenues for future research and policy implications were discussed. The pandemic demonstrated a need for building more resilient and adaptive healthcare systems, enhancing crisis preparedness along with rapid and effective responses.

To Operate or Not? Balancing Advanced Imaging, Machine Learning, and the Doctor-Patient Relationship in Complex Clinical Decision Making

Advances in high-resolution, cross-sectional imaging have changed the practice of medicine. These innovations have clearly benefited patient care yet have also led to a decreased dependence on the art of medicine, with its emphasis on obtaining a thoughtful history and thorough physical examination to elicit the same diagnosis that imaging provides. What remains to be determined is how physicians can balance these technological advances with their own ability to use clinical experience and judgment. This can be seen not only with the use of high-level imaging but also with the increasing use of machine-learning models throughout medicine. The authors contend that these should be seen not as a replacement for the physician, but as another tool in their arsenal in determining management decisions. These issues are salient for surgeons, who, given the serious undertaking required to operate on a person, must develop trust-based relationship with their patients. Navigating this new field brings with it several ethical conundrums that must be addressed, with the final goal being to provide optimal patient care without sacrificing the human element involved, from either the physician or the patient. The authors examine these less-than-simple challenges, which will continue to develop as physicians use the increasing amount of machine-based knowledge available to them.

Impact of computerised provider order entry on the quality and quantity of clinical information included with investigation requests: an interrupted time series analysis

INTRODUCTION

Relevant clinical information is vital to inform the analytical and interpretative phases of most investigations. The aim of this study is to evaluate the impact of implementation of computerised provider order entry (CPOE), featuring order-specific electronic order entry forms (eOEFs), on the quality and quantity of clinical information included with investigation requests.

METHODS

The CPOE module of a commercially available electronic health record (Cerner Millennium) was implemented at a large, tertiary care centre. The laboratory information management system was interrogated to collect data on specimens sent for microbiological culture 1 year before implementation of CPOE (2018), immediately post implementation (2019) and 6 months post implementation (2020). An interrupted time series analysis was performed, using text mining, to evaluate the quality and quantity of free-text clinical information.

RESULTS

In total, 39 919 specimens were collected from 16 458 patients. eOEFs were used to place 10 071 out of 13 735 orders in 2019 (73.3%), and 9155 out of 12 229 orders in 2020 (74.9%). No clinical details were included with 653 out of 39 919 specimens (1.6%), of which 22 (3.4%) were ordered using eOEFs. The median character count increased from 14 in 2018, to 41 in 2019, and 38 in 2020. An anti-infective agent was specified in 581 out of 13 955 requests (4.2%) in 2018; 5545 out of 13 735 requests (40.4%) in 2019; and 5215 out of 12 229 requests (42.6%) in 2020. Ciprofloxacin or piperacillin-tazobactam (Tazocin) were mentioned in the clinical details included with 421 out of 15 335 urine culture requests (2.7%), of which 406 (96.3%) were ordered using eOEFs. Subsequent detection of in vitro non-susceptibility led to a change in anti-infective therapy for five patients.

CONCLUSIONS

Implementation of CPOE, featuring order-specific eOEFs, significantly and sustainably improves the quality and quantity of clinical information included with investigation requests, resulting in changes to patient management that would not otherwise have occurred.

Patient Sociodemographic Characteristics Associated With Saturday Breast Imaging Clinic Utilization

OBJECTIVE

To determine patient sociodemographic characteristics associated with breast imaging utilization on Saturdays to inform potential initiatives designed to improve access and reduce disparities in breast cancer care.

METHODS

This was an IRB-approved retrospective cross-sectional study. All adult women (aged ≥18 years) who received a screening or diagnostic examination at our breast imaging facility from January 1, 2016 to December 31, 2017 were included. Patient characteristics including age, race, primary language, partnership status, insurance status, and primary care physician status were collected using the electronic medical record. Multiple variable logistic regression analyses were performed to evaluate patient characteristics associated with utilization.

RESULTS

Of 53 695 patients who underwent a screening examination and 10 363 patients who underwent a diagnostic examination over our study period, 9.6% (5135/53 695) and 2.0% (209/10 363) of patients obtained their respective examination on a Saturday. In our multiple variable logistic regression analyses, racial/ethnic minorities (odds ratio [OR], 1.5; 95% confidence interval [CI]: 1.4-1.6; P < 0.01) and women who speak English as a second language (OR, 1.1; 95% CI: 1.0-1.3; P = 0.03) were more likely to obtain their screening mammogram on Saturday than their respective counterparts.

CONCLUSION

Racial/ethnic minorities and women who speak English as a second language were more likely to obtain their screening mammogram on Saturdays than their respective counterparts. Initiatives to extend availability of breast imaging exams outside of standard business hours increases access for historically underserved groups, which can be used as a tool to reduce breast cancer-related disparities in care.

COMPARISON OF PULMONARY NODULE DETECTION, READING TIMES AND PATIENT DOSES OF ULTRA-LOW DOSE CT, STANDARD DOSE CT AND DIGITAL RADIOGRAPHY

The purpose of the present work was to evaluate performance in pulmonary nodule detection, reading times and patient doses for ultra-low dose computed tomography (ULD-CT), standard dose chest CT (SD-CT), and digital radiography (DR). Pulmonary nodules were simulated in an anthropomorphic lung phantom. Thirty cases, 18 with lesions (45 total lesions of 3-12 mm) and 12 without lesions were acquired for each imaging modality. Three radiologists interpreted the cases in a free-response study. Performance was assessed using the JAFROC figure-of-merit (FOM). Performance was not significantly different between ULD-CT and SD-CT (FOMs: 0.787 vs 0.814; ΔFOM: 0.03), but both CT techniques were superior to DR (FOM: 0.541; ΔFOM: 0.31 and 0.28). Overall, the CT modalities took longer time to interpret than DR. ULD chest CT may serve as an alternative to both SD-CT and conventional radiography, considerably reducing dose in the first case and improving diagnostic accuracy in the second.

Multidisciplinary quality improvement initiative to optimize acute neurovascular imaging for transient ischemic attack or minor stroke

BACKGROUND

Neurovascular imaging for patients with high-risk transient ischemic attack (TIA) or minor stroke in the emergency department (ED) with computed tomography angiography (CTA) of the head and neck is the guideline-recommended standard of care, but it is underutilized in routine practice. We conducted a quality initiative to improve adherence to guidelines.

METHODS

Between January 2017 and March 2019, we implemented a decision support tool integrated into the electronic ordering system to guide ED physicians to order a CTA on patients with high-risk TIA or minor stroke defined as ongoing neurological deficits in the ED or resolved motor or speech deficits in the preceding 48 h. Data were collected retrospectively pre-intervention and prospectively post-intervention. We used an interrupted time-series analysis for the before-after comparison of the use of CTA among patients who met criteria (main process measure) and those who did not meet criteria (balancing measure).

RESULTS

Among 861 patients with TIA or minor stroke, the proportion of patients with high-risk events imaged with a CTA in the ED increased from 12.0% pre-intervention to 77.0% post-intervention and this shift was sustained over 11 months. CTA use in those without high-risk events increased to a lesser extent (15.3% versus 42.9%). The interrupted time-series analysis showed a step change immediately post-intervention where the increase in CTA use in patients with high-risk events was 51.7% higher than its use in those without high-risk events (p < 0.001). Compared to pre-intervention, the median ED length of stay increased by 2 h and neurology consultation in the ED was more frequent (5.8% versus 19.5%) post-intervention.

CONCLUSION

We provide a detailed framework that improved adherence to acute imaging guidelines for patients with TIA or minor stroke and anticipate that our approach could improve acute imaging for such patients in most EDs.