No single solution exists for alleviating crowding in emergency rooms, but a new study identifies four key strategies that have reduced the problem.
The study concludes that engaged executive leadership can alleviate the problem when combined with a data-driven approach and coordination across the hospital from housekeepers to the CEO. Crowding in emergency rooms has been associated with decreased patient satisfaction and even death.
“Emergency department crowding can be dangerous for patients,” said senior author Benjamin Sun, M.D., a professor of emergency medicine in the OHSU School of Medicine. “We know, for example, that emergency department crowding can lead to delays in pain medications for patients with broken bones, as well as delays in antibiotics for patients with pneumonia. We know the risk of death is higher when the emergency department is more crowded than when it’s less crowded.”
The study identified groups of hospitals categorized as low, high or highest-improving in terms of lengths of stay and boarding times (the length of time an admitted patient must wait for an inpatient bed), as measured through statistics provided by 2,619 U.S. hospitals to the Centers for Medicare and Medicaid Services. The authors picked a representative sample of four hospitals in each of the three categories of performance, then systematically interviewed a broad range of stakeholders.
The researchers talked to 60 people at the 12 hospitals. Interviewees included nursing staff, emergency department directors, directors of inpatient services, chief medical officers and other executive officers.
The study identified four key strategies:
1) Involvement of executive leadership: The study noted that executive leaders in highperforming hospitals identified hospital crowding as a top priority complete with clear goals and resources to achieve those goals.
“In contrast, low performing hospital executive leadership did not prioritize crowding initiatives, despite acknowledging the causes,” the authors wrote. “Emergency department leadership often felt isolated in their struggle with significant boarding and lengths of stay.”
2) Hospital-wide coordinated strategies: High-performing hospitals performed as a cohesive system across departments to alleviate crowding, in contrast to low-performing hospitals that operated in silos. For example, one executive at a high-performing hospital developed strategies for improving bed turnaround times on inpatient rooms.
“Instead of waiting for the room to go from dirty to clean and then to book transportation for a patient to come, we started doing things in parallel so that we would cut down on waiting time,” the executive said in the report.
3) Data-driven management: High-performing hospitals gathered and used data to adjust operations in real time, provided immediate feedback to key personnel, and predicted patterns of flow in the emergency department and hospital, matching resources to meet expected demand.
“In contrast, at low-performing hospitals, data were most often available only retrospectively, and, if the data were used, they were discussed by executive leadership at monthly or quarterly meetings,” the authors wrote.
4) Performance accountability: High-performing hospitals held staff accountable and problems were addressed immediately to reduce crowding.
Sun described a typical scenario in one high-performing hospital: “If boarding in the ED exceeded the acceptable limit, the chief medical officer would physically get out of the office, go onto the ward floors, and start reviewing charts and asking, ‘What can we do to fix the problem?’” he said.
OHSU School of Medicine
http://tinyurl.com/y8bq3gvg

Human rhinovirus (HRV), the culprit behind most colds, is the leading cause of hospitalization for premature babies. However, in very preterm children, exactly how HRV causes severe respiratory disease — and which patients may need more intensive observation and treatment — is less well understood.
A new study led by Children’s National Health System research clinicians showed that in children who were born severely premature, HRV infections seem to trigger an airway hyper-reactivity (AHR) type of disease, which leads to wheezing and air-trapping (hyperinflation) and more severe respiratory disease. This, in turn, increases the risk for hospitalization.
The study found that other signs of respiratory distress, such as low arterial blood oxygen or rapid shallow breathing, were no more common in severely premature children (less than 32 weeks of gestational age) than in kids born preterm or full-term. The findings have implications for administering supportive care sooner or more intensively for severely premature children than for other infants.
“When it comes to how they respond to such infections, severely premature children are quite different,” says Geovanny Perez, M.D., a specialist in pulmonary medicine at Children’s National and lead study author. “We’ve known they are more susceptible to human rhinovirus infection and have more severe disease. However, our study findings suggest that severely premature kids have an ‘asthma’ type of clinical picture and perhaps should be treated differently.”
The study team sought to identify clinical phenotypes of HRV infections in young children hospitalized for such infections. The team theorized that severely premature babies would respond differently to these infections and that their response might resemble symptoms experienced by patients with asthma.
“For a number of years, our team has studied responses to viruses and prematurity, especially HRV and asthma,” Dr. Perez says. “We know that premature babies have an immune response to HRV from the epithelial cells, similar to that seen in older patients with asthma. But we wanted to address a gap in the research to better understand which children may need closer monitoring and more supportive care during their first HRV infection.”
In a retrospective cross-sectional analysis, the study looked at 205 children aged 3 years or younger who were hospitalized at Children’s National in 2014 with confirmed HRV infections. Of these, 71 percent were born full-term (more than 37 gestational weeks), 10 percent were preterm (32 to 37 gestational weeks) and 19 percent were severely premature (less than 32 gestational weeks).
Dr. Perez and his team developed a special respiratory distress scoring system based on physical findings in the children’s electronic medical records to assess the degree of lower-airway obstruction or AHR (as occurs in asthma) and of parenchymal lung disease. The physical findings included:

• Wheezing;
• Subcostal retraction (a sign of air-trapping/hyperinflation of the lungs), as can occur in pneumonia;
• Reduced oxygen levels (hypoxemia); and
• Increased respiratory rate (tachypnea).

The research team assigned each case an overall score. The severely premature children had worse overall scores — and significantly worse scores for AHR and hyperinflated lungs relative to children born late preterm or full-term.
“What surprised us, though, in this study was that the phenotypical characterization using individual parameters for parenchymal lung disease, such as hypoxemia or tachypnea, were not different in severe preterm children and preterm or full term,” says Dr. Perez. “On the other hand, our study found that severely preterm children had a lower airway obstruction phenotype associated with retractions and wheezing. Moreover there was a ‘dose effect’ of prematurity: children who were born more premature had a higher risk of wheezing and retractions.”
Among the implications of this study, Dr. Perez sees the potential to use phenotypical (clinical markers, such as retractions and wheezing) and biological biomarkers to better personalize patients’ treatments. Dr. Perez and his team have identified biological biomarkers in nasal secretions of children with rhinovirus infection that they plan to combine with clinical biomarkers to identify which patients with viral infections will benefit from early supportive care, chronic treatments or long-term monitoring.
ScienceDailyhttps://tinyurl.com/yd3mz3eu

Having a loved one go through a critical illness is a stressful and traumatic experience that may have lasting effects months after the patient is discharged from the intensive care unit (ICU). To improve the well-being of both patients and family during this vulnerable time, a set of new guidelines has been released, providing physicians with evidence-based strategies to optimize outcomes for the critically ill and those at their bedside.
“There is increasing awareness that support for family can also improve patient outcomes,” said Judy Davidson, lead author of the guidelines and a nurse at UC San Diego Health. “Families in the ICU aren’t visitors — they are an integral part of the care and the care team.”
Based on an analysis of more than 450 qualitative and quantitative studies, a multidisciplinary, international panel of 29 health care experts developed a series of recommendations for family-centred care, defined as an approach to healthcare that is respectful of and responsive to individual families’ needs and values. The experiences and perspectives of former ICU patients and family members from UC San Diego Health, the University of Maryland (UOM) School of Medicine, patient advocacy organizations and the LGBTQ community were used to develop the new guidelines.
The 23 recommendations grouped into five categories include: space for loved ones to sleep; educational programmes to teach family how to assist with care; encouraging family members to be part of the decision-making process; implementing ICU diaries to reduce a family’s anxiety and post-traumatic stress; and involving a multi-disciplinary team, such as psychologists, social workers and spiritual advisors. UC San Diego Health is among the first hospitals in the nation to embrace the concept of implementing a family diary in the ICUs.
“Structured interventions and approaches to support family members of critically ill patients are needed both to mitigate the impact of the crisis of critical illness and to prepare family members for decisionmaking and caregiving demands,” said Davidson. “Up to half of families with a critically ill loved one experience psychological symptoms. A robust programme built around family-centred care may decrease the negative impact surrounding critical illness. It is a matter of public health.”
The guidelines suggest that clinicians and institutions need to decide which intervention or combination of interventions are likely to be the most successful in specific circumstances.
“We have developed a self-analysis tool that ICUs can use to build a customized family-centered plan that will bring change,” said Robert El-Kareh, MD, MPH, hospitalist at UC San Diego Health and associate professor at UC San Diego of Medicine, who was instrumental in building translational tools to help ICUs move recommendations into practice.

University of California – San Diego http://tinyurl.com/y732jdfk

In a review article, physicians at Johns Hopkins, along with experts from several other institutions across north America, compiled published evidence and crafted an experience-based quality improvement blueprint to reduce repetitive lab testing for hospitalised patients.
Repeated blood draws for such tests can lead to hospital-acquired anaemia and other complications. This is the second paper co-authored by residents and faculty from the High Value Practice Academic Alliance, a consortium of nearly 90 academic medical centres collaborating to improve health care quality and safety by reducing unnecessary components of practice that do not add value to patient care.
“Excessive blood draws can deplete a patient’s haemoglobin count, which often leads to repeat testing,” says Kevin Eaton, M.D., a third-year internal medicine resident at The Johns Hopkins Hospital. Others have estimated that nearly 20 percent of hospitalised patients can develop moderate to severe hospital-acquired anaemia. This spiral, he and his co-authors assert, can generate additional unnecessary tests, interventions and costs for the patient. Moreover, says the authors, published studies show that decreasing repetitive daily laboratory testing did not result in missed diagnoses or increase the number of readmissions to the hospital.
Citing individual studies where front-line health care workers reduced the number of orders for lab tests by anywhere between 8 percent and 19 percent, the authors reported that cost savings have ranged from $600,000 to more than $2 million per year. Says Eaton, while many professional societies have recommended reducing repetitive lab tests, recommendations alone typically do not change behaviour. The most successful efforts to reduce daily lab testing in this review included a combination of educating health care providers about charges, obtaining feedback by showing providers’ ordering habits and changing clinical workflow to restrict automated repeat ordering of tests.
 
The recommendations are as follows:
Design hospital-wide educational initiatives backed by data to collectively outline and standardize best practice.
Establish target numbers by which to reduce lab test ordering and provide instant feedback to those ordering tests to show their personal ordering patterns, so they are aware of their own behavior with respect to agreed-upon standards.
Reprogram the electronic systems used to order tests to restrict the number of “pre-ordered” tests with an eye on having better reasons to order tests than just doing so daily.
“Reducing unnecessary daily inpatient laboratory testing is only one small improvement, but doing so successfully can help change the culture of health care providers to be more keenly focused on thoughtful ordering and prescribing for their patients,” says Pam Johnson, M.D., associate professor of radiology, who was not involved in this study. Says Johnson, who leads the High Value Practice Academic Alliance, “improving patient safety and patient outcomes are the goals here, and an additional benefit to reducing the number of unnecessary diagnostics is also a reduction in the financial burden to the patient.”

John Hopkins Hospital
www.hopkinsmedicine.org/news/media/releases/experts_recommend_fewer_lab_tests_for_hospitalized_patients

Opioid-free general anaesthesia is safe, effective and dramatically decreases postoperative nausea, according to a single-centre study of more than 1,000 patients.
Using opioid alternatives during general anaesthesia is part of an effort by TEAMHealth Anesthesia at Select Physicians Surgery Center in Tampa, Florida to reduce the use of opioids during and after surgery. The study findings suggest physician anaesthesiologists are helping pave the way to promote pain management alternatives to opioids, and making headway in reducing the use of the addictive medications.
“Opioids crept into general anaesthesia over the years because they don’t cause problems with the cardiovascular system, but our research suggests we can use alternatives safely and effectively,” said David Samuels, M.D., lead author of the study and medical director of anaesthesia at Select Physicians Surgery Center and medical director for TEAMHealth Anesthesia, Tampa. “By avoiding the use of opioids intraoperatively and helping surgeons understand the value and importance of offering patients different options for pain after surgery, physician anaesthesiologists can be agents of change in addressing the opioid dependency crisis.”
Opioids – usually fentanyl, an opioid 50 times more powerful than heroin – are typically included in the combination of medications given to patients for general anaesthesia during surgery. In the study, 1,009 patients having head and neck surgery (including laryngoscopy, complex facial plastic surgery, middle ear surgery and nasal or sinus surgery) received general anaesthesia without opioids. Instead, patients received various combinations of magnesium, sub-anaesthetic ketamine, lidocaine and ketorolac, depending on the patient’s age and health. Surgeons and patients expressed a high degree of satisfaction with the new anaesthesia protocol and postoperative pain management.
After surgery, 11 percent of patients experienced nausea, whereas 50 to 80 percent of patients typically suffer from nausea after surgery. Additionally, 64 percent of patients did not require any pain medication in the PACU.
The traditional use of fentanyl in general anaesthesia can cause hyperalgesia, or increased sensitivity to pain, Dr. Samuels said.
“Hyperalgesia leads to increased pain, so patients request more opioids in the recovery area, and then go home with an excessive number of pills,” said Enrico M. Camporesi, M.D., co-author of the study and professor emeritus at the University of South Florida and director of research for TEAMHealth Anesthesia Research Institute, Tampa. “We believe that not using fentanyl during surgical anaesthesia, as well as not providing patients too many pills after surgery, may help decrease the likelihood of opioid abuse. Studies show that 1 in 15 patients who has surgery is still taking prescription opioids 90 days afterwards,” he said.
Three of the 19 surgeons who participated in the study now prescribe patients daily oral magnesium, gabapentin and ibuprofen for pain management after surgery. They also prescribe five hydrocodone pills for any breakthrough pain. Previously, these surgeons prescribed 50 hydrocodone pills. The change to five pills will lead to 27,000 fewer prescribed hydrocodone pills in one year’s time for these surgeons at their practice.
American Society of Anesthesiologists (ASA) www.asahq.org/about-asa/newsroom/news-releases/2017/10/eliminating-opioids-from-anesthesia-decreases-post-surgery-nausea